Since this video was published, HHS issued a rule finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearinghouses to transition to ICD-10.
In this MLN Connects™ video, Sue Bowman from the American Health Information Management Association (AHIMA) provides a basic introduction to ICD-10 coding.
– Similarities and differences from ICD-9
– ICD-10 code structure
– Coding process and examples
– 7th Character
– Placeholder “x”
– Excludes notes
– Unspecified codes
– External cause codes
Visit the video detail web page for links to the slide presentation and written transcript:
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I am Leah Nguyen from the provider Communications Group here at CMS I would like to welcome you to today's mln connects video on the International classification of diseases 10th edition or icd-10 are you ready to transition to icd-10 on October 1st 2014 now is the time to prepare today we will be discussing icd-10 basics and we have a special guest speaker sue Bowman from the American Health Information Management Association or AHIMA Thank You Leah in this video I will be providing a basic introduction to the icd-10-cm code set the objective is not to provide comprehensive coding training but to allow viewers to gain basic familiarity with the similarities and differences between icd-9-cm and icd-10-cm as well as a basic understanding of the icd-10-cm structure and coding process slide 3 shows the differences between the icd-9-cm and icd-10-cm code structure icd-10-cm codes have three characters before the decimal and up to four characters after the decimal codes are alphanumeric with the first character always being alpha all letters except the letter U are used alpha characters are not case-sensitive as depicted in the right ankle sprain example whereby the Alpha characters can be either lower or upper case without affecting the code meaning it sounds like a big change are there any similarities to icd-9 as indicated on the next few slides icd-10-cm has a number of similarities to icd-9 cm in both code sets the tabular list is a chronological list of codes divided into chapters based on the body system or condition both code sets have a hierarchical structure icd-10-cm chapters are structured similarly to icd-9 cm with a few exceptions a few chapters have been restructured and the sense organs have been moved from the nervous system chapter to their own chapters in both icd-9-cm and icd-10-cm the index is an alphabetical list of terms and their corresponding codes just as in icd-9-cm indented subterms appear under the main terms in the icd-10-cm index the index structure is the same in both code sets meaning there is an alphabetic index of diseases and injuries and alphabetic index of external causes a table of neoplasms and a table of drugs and chemicals many conventions such as abbreviations punctuation symbols and instructional notes have the same meaning in both icd-9-cm and icd-10-cm just as in icd-9-cm icd-10-cm has unspecified codes for use when no information is available to support a more specific code I will be discussing unspecified codes in more detail later on codes are looked up the same way in icd-9-cm in an icd-10-cm and in both code sets a code is invalid if it is missing an applicable character just as with icd-9 cm official guidelines for coding and reporting accompany the icd-10-cm conventions and instructions and adherence to these guidelines is required under HIPAA I'm sure that coders will find these many areas of similarity between icd-9 and icd-10 reassuring but there are differences that coders Deaton be aware of could you identify some areas where new concepts have been added to icd-10 sure as indicated on slide 9 icd-10-cm does have some important differences from icd-9 cm the biggest difference is the expanded detail and specificity icd-10-cm codes reflect modern medicine and updated medical terminology the concept of laterality has been added to some chapters the use of combination codes has been expanded such as the creation of combination codes for certain conditions and their associated common symptoms or manifestations or combination codes for poisonings and the associated external cause slide 10 provides a few examples of some of the new combination codes and icd-10-cm as shown on slide 11 injuries are grouped by anatomical site rather than by type of injury in the tabular list however you would still look up the term for the type of injury such as fracture or sprain in the alphabetic index we always get a lot of questions about the use of the seventh character in icd-10 could you explain how this will work sure a seventh character is used in certain chapters such as musculoskeletal obstetrics injuries and external causes seventh characters are also used in a few other places outside of these particular chapters the seventh character has a different meaning depending on the section where it is being used it must always be used in the seventh character position and when a seventh character applies codes that are missing this character are considered invalid as shown on slide 13 identification of the type of encounter is an example of a circumstance when a seventh character is used for example a seventh character identifying whether the encounter is initial subsequent or sequela is used in the injury chapter the seventh character for initial encounter is not limited solely to the very first encounter for the evaluation of a condition this seventh character can be used for multiple encounters as long as the patient continues to receive active treatment for the condition examples of active treatment are initial evaluation of the condition which may be in the emergency room or at a physician's office or clinic encounter for surgical treatment of the condition and referral for evaluation and treatment by a new physician such as when the emergency department physician refers the patient to an orthopedist where the first orthopedist evaluating the patient sends him to a specialist the 7th character for subsequent encounter is to be used for all encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during healing or recovery phase examples of subsequent encounters include cats change or removal removal of external or internal fixation device medication adjustments and other aftercare and follow-up visits following active treatment of the injury or condition encounters for therapy such as physical and occupational therapy are another example of the use of the subsequent encounter seventh character when using 7th character for sequela s it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself the S is added only to the injury code not the sequela code the 7th character s identifies the injury responsible for the sequela the specific type of sequela for example a scar is sequenced first followed by the injury code slide 14 provides examples of some of the 7th characters for fracture codes including initial encounter for open versus closed fracture subsequent encounter for fracture with routine healing and delayed healing subsequent encounter for fracture with nonunion or malunion and sequela that makes sense but don't some icd-10 codes contain an X what is the purpose of the X and how is this used as explained on slide 15 another new feature as you mentioned is the use of a dummy placeholder X which is used in certain codes to allow for future code expansion or to fill in empty characters when a code contains fewer than 6 characters and a 7th character applies as with all other Alpha characters in icd-10-cm the placeholder X is not case-sensitive when a placeholder character is applicable it must be used in order for the code to be valid so I know a lot of coders are wondering when to use the excludes notes in icd-10 aren't there two types in icd-10 you are right Leah and excludes1 note means that the code identified in the note and the code where the note appears cannot be reported together because the two additions are mutually exclusive in the example on slide 16 there is an excludes1 note under category 10 type 1 diabetes for other types of diabetes since the patient can only have one type of diabetes codes for different types of diabetes can't be used together on the same record an excludes2 note indicates that the condition identified in the note is not part of the condition represented by the code where the note appears so both codes may be reported together if the patient has both conditions in the example on slide 17 there is an excludes2 note under category l89 pressure ulcer for other types of skin ulcers as well as skin infections since a patient could have other types of skin ulcers or a skin infection in addition to a pressure ulcer slide 18 shows some examples of the expanded specificity in icd-10-cm whereas slide 19 shows examples of laterality this is great background information on icd-10 do you think you can walk us through a few examples of how to go through assigning an icd-10 code I would be happy to beginning with slide 20 let's walk through a few coding examples to demonstrate how similar the process is to the icd-9-cm coding process to code a diagnosis of type 1 diabetes with diabetic nephropathy start by looking up the main term diabetes in the alphabetic index just as you would in icd-9 cm under the main term diabetes there are sub entries for type 1 with nephropathy with code e 10 point 2 1 listed next look up this code number in the tabular list and verify the code e 10 point 2 1 is the code for type 1 diabetes with diabetic nephropathy in the next example on slide 22 look up the main term societies in the alphabetic index and then find indented subterms for acute and then with hematuria icd-10-cm code and third point zero one is listed so next go to the tabular list to verify that this code is correct for diagnosis of acute cystitis with hematuria notice there is an instructional note under category and 30 indicating that an additional code can be assigned to identify the infectious agent so if the provider has documented the infectious agent causing the Sustaita s– you would assign an additional code to identify the organism so these are great clinical examples do you have any examples for an injury injuries are handled somewhat differently in icd-10 I will address how to code a fracture in the example on slide 24 when you look up fracture traumatic scaphoid hand in the index there are no sub entries and a note directs you to see also fracture carpal navicular when you look up fracture carpal bones navicular there is a sub entry for proximal third when you look up s60 2.03 in the tabular you will first notice two notes under s62 stating that a fracture not indicated as displaced or non-displaced should be coded to displaced and that a fracture not indicated as open or closed should be coded to closed you will see that there are 7th characters that apply to the s62 codes therefore is shown on slide 26 there are more characters to the correct code assignment than the five characters shown in the index the correct code for an initial encounter for a traumatic fracture of the proximal third of the scaphoid bone of the left wrist is s60 2.03 to a displaced fracture of proximal third of navicular scaphoid bone of left wrist initial encounter for closed fracture although the documentation of the diagnosis didn't indicate whether the fracture was displaced or non-displaced or open or closed / the instructional notes under s62 it is coded as displaced and closed in the example on slide 27 the patient was admitted to a rehabilitation facility for physical and occupational therapy following hospitalization for a fracture of the left femoral neck when you look up fracture femur femoral neck in the alphabetic index a note says to see fracture femur upper and neck the index entry for fracture femur upper and neck refers you to s 72 point zero zero when you look up s 72 in the tabular list you will see the same notes regarding displaced versus non displaced and open versus closed fractures that I mentioned earlier you will also see a number of 7th characters that are applicable to codes in category s 72 as shown on slide 29 the correct code assignment is s 72 point zero zero to D fracture of unspecified part of neck of left femur subsequent encounter for closed fracture with routine healing as indicated by the instructional note under s 72 fractures not specified as open or closed are coded as closed and you will recall from my earlier explanation of the 7th characters for initial and subsequent encounters that a subsequent encounter is one that occurs after the patient has received active treatment of the condition and is receiving routine cure for the condition during the healing or recovery phase this would include admissions or encounters for therapy services you may have noticed from some of the examples I've provided that it is important not to code directly from the index and to always verify the code number in the tabular the index may only guide you to the first few characters of the code and you will need to go to the tabular to determine the rest of the characters including any applicable 7th character see that was an excellent example of how to code an injury and the use of the seventh digit could you give us a few more common clinical coding examples such as for pregnancies morbid obesity and pre-admission school examinations I would be happy to the next coding example on slide 30 is placenta previa with hemorrhage second trimester you might know to start by looking up pregnancy complicated by in the index but if you didn't and you started by looking up the term placenta in the index you are directed to the term see pregnancy complicated by specified condition so then you know to look under the main term of pregnancy complicated by where you will see placenta previa listed as a sub entry you know from the diagnosis that it is with hemorrhage so look up o 44.1 in the tabular to verify the complete code number as shown on slide 31 the correct code number is Oh 40 4 point 1 2 plus center previa with hemorrhage second trimester for the morbid obesity example on slide 32 look up the main term obesity in the index and then find the indented sub entry morbid where you'll see Cody sixty six point zero one listed when you look up East 66 point zero one in the tabular you will see a note under East 66 indicating that an additional code should be assigned if the body mass index or BMI is known in this case the BMI is known to be 46 so code Z 68 point 42 is assigned in addition to code East sixty six point zero one for a child receiving a physical for admission to preschool look up the main term examination medical and then the indented sub entries preschool children then for admission to school in the index as shown on slide 34 as verified in the tabular code Z zero two point zero is the correct code although the code title is not specific to examinations for admission to preschool the index entry and inclusion term of encounter for examination for admission to preschool education under this code confirmed that this is the correct code those are great examples but how will unspecified codes be used in icd-10 there have been a number of questions and concerns expressed that unspecified codes will not be accepted reporting icd-10 codes can you clarify what unspecified codes are and how they should be used just as in icd-9-cm icd-10-cm contains unspecified or not otherwise specified codes for use when sufficient clinical information isn't known or available about a particular health condition to assign a more specific code as stated on slide 36 unspecified codes have acceptable even necessary uses while specific diagnosis codes should be reported when they are supported by the available medical record documentation and clinical knowledge of the patient's health condition there are instances when signs and symptoms or unspecified codes are the best choices for accurately reflecting the healthcare encounter unspecified codes are for use when the documentation is insufficient to assign a more specific code or the provider doesn't have sufficient clinical information about the patient's condition for a more specific code to be assigned it would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code however since the use of nonspecific codes impacts the quality of coded data and limits the value of icd-10-cm these codes should only be used when no specific code is available or a more specific diagnosis is not yet known for an example of assigning an unspecified code let's take a look at the left wrist fracture we coded earlier this time we don't have the information about the specific bone that's fractured all we know is that it is the left wrist we'll also make this encounter a follow-up visit for the fracture which is healing well if shown on slide 37 look up the main term fracture wrist in the alphabetic index you are directed to s 62 point one zero fracture of unspecified carpal bone which as indicated on slide 39 has an inclusion term for fracture of wrist and OS meaning not otherwise specified you know the fracture is on the left side so the correct code is s 62.1 zero to D the appropriate seventh character is d because this is a follow-up visit so it is a subsequent encounter the fracture is healing well so you would assign D for subsequent encounter with routine healing rather than G for subsequent encounter with delayed healing on slide 40 the only information you know about the diagnosis is that it is pneumonia look up the main term pneumonia in the index which directs you to code J 18.9 on slide 41 when you look up J 18.9 pneumonia unspecified organism in the tabular you will see it is the correct code finally could you go over external cause codes as stated on slide 42 there is no national requirement for mandatory reporting of icd-10-cm codes in chapter 20 external causes of morbidity reporting of these codes is only required for providers subject to a state-based external cause code reporting mandate or a payer requirement however in the absence of a mandatory reporting requirement providers are encouraged to voluntarily report external cause codes because these codes have significant value for example these codes provide valuable data for injury research and evaluation of injury prevention strategies external cause of injury data are used at the national state and local levels to identify high-risk populations set priorities and plan and evaluate injury prevention programs and policies and are potentially useful for evaluating emergency medical services and trauma care systems collection and ready access to complete and reliable external cause of injury data are important for data-driven decision-making on public health policy and priorities setting at the federal state and local levels high quality injury morbidity data on healthcare utilization and cost associated with specific external causes of injury are critical to accurately estimate the impact of targeted cause specific prevention efforts on the healthcare system and society improving the availability of and access to high-quality external cause data can benefit auto insurance companies disability insurers health insurance plans public payers health care purchasers employers businesses labor unions schools and other entities interested in injury prevention and safety issues assigning an external cause code is similar to assigning other icd-10-cm codes in the example of an injury sustained from falling down ice-covered steps on slide 44 look up the main term fall falling in the external cause index then the indented subterms from off out of then stairs steps and then due to ice or snow the index directs you to w0 0.1 fall from stairs and steps due to ice and snow note on slide 45 codes in category w0 0 require a 7th character this is an initial encounter so the appropriate 7th character is a since w0 0.1 only has four characters and the a must appear in the 7th character position this is an example of a situation when the placeholder X should be used insert two X's after the one to create six characters and then add the seventh character a at the end for a final code of W 0 0.1 X X a in the example on slide 46 a bicyclist sustained injuries from a collision with a car in an intersection a bicyclist is referred to as a pedal cyclist in icd-10-cm lookup accident pedal cycle the external cause index this term refers you to the term accident transport pedal cyclist when you look up this term you will see indented sub entries for driver than collision with them car traffic which directs you to V thirteen point four as shown on slide 47 this code requires a seventh character so since there are only four characters in V thirteen point four two placeholder X's are added after the four to create a six character code and then the seventh character a is added at the end of the code since this was an initial encounter the final code assignment is V thirteen point four X X a that is all the time we have I would like to thank our special guest speaker sue Bowman from AHIMA for taking time to share her knowledge of icd-10 coding more information on these topics is available on the icd-10 website at WWF I see d-10 thank you and have a nice day this mln connects video is part of the Medicare Learning Network the information presented in this presentation was correct as of the date it was recorded this presentation is not a legal document official Medicare program legal guidance is contained in the relevant statutes regulations and rulings