Documentation and ICD-10 Coding Jeffrey D. Lehrman, DPM, FASPS, MAPWCA APMA Coding Committee Expert Panelist, Codingline APMA MACRA Task Force Fellow, American Academy of Podiatric Practice Management Board of Directors, ASPS Board of Directors, APWCA Twitter: @DrLehrman
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Documentation and ICD-10 Coding - American Podiatric … and ICD-10... · · 2017-05-24Documentation and ICD-10 Coding Jeffrey D. Lehrman, DPM, FASPS, MAPWCA . APMA Coding Committee
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Documentation and ICD-10 Coding
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA
APMA Coding Committee
Expert Panelist, Codingline
APMA MACRA Task Force
Fellow, American Academy of Podiatric Practice Management
Board of Directors, ASPS
Board of Directors, APWCA
Twitter: @DrLehrman
Presenter
Presentation Notes
October 1, 2015 forgiveness
DFU Coding
Type 2 diabetic patient with a chronic diabetic left lateral midfoot ulcer with necrosis of muscle. The patient takes insulin on a daily basis.
•L97.423 •Non-pressure chronic
ulcer of left heel and midfoot with necrosis of muscle
•E11.621 • Type 2 diabetes mellitus
with foot ulcer
DFU Coding Type 2 diabetic patient with chronic diabetic
left foot lateral midfoot ulcer with necrosis of muscle. The patient takes insulin on a daily basis.
• E11.621 Type 2 diabetes mellitus with left foot ulcer • Z79.4 Long term (current) use of insulin • L97.423 Non-pressure chronic ulcer of left heel and midfoot with necrosis of muscle
DFU Documentation
ICD 9 Chronic Midfoot ulcer in Type 2 diabetic
ICD 10 Chronic, non-pressure left midfoot ulcer with necrosis of muscle in a type 2 diabetic with long term insulin use
ICD 9 vs. ICD 10
Initial encounter for a closed, nondisplaced, Left 2nd toe proximal phalanx fracture ICD 9: 826.0: Closed fracture of phalanx of foot
• Initial encounter for a closed, nondisplaced, Left 2nd toe proximal phalanx fracture
• ICD 10: S92.515A (nondisplaced fracture of proximal phalanx of left lesser toe(s), initial encounter for closed fracture
• Documentation: • Closed, nondisplaced left 2nd toe proximal
phalanx fracture
ICD 9 vs. ICD 10
ICD 9 Fracture, phalanx, closed
ICD 10 Closed, nondisplaced left 2nd toe proximal phalanx fracture
• Non-fracture care • A – initial encounter • D – subsequent encounter • S – sequela
• Fracture care
• • • • • • •
A – initial encounter for closed fracture B – initial encounter for open fracture D – subsequent encounter for normal healing fracture G – subsequent encounter for delayed healing fracture K – subsequent encounter for fracture with non-union P – subsequent encounter for fracture with mal-union S – sequela of fracture
Sequela
• Generally 2 codes need to be used in the following order: • The condition or nature of the sequela is coded first. • Then the sequela code (what caused it) is second.
Sequela of Prior Ankle Sprain
• Chronic left ankle instability following Grade III sprain of the calcaneofibular ligament six months prior. ICD – 9: 728.4 – Ligamentous Laxity, Ankle
• M24.272
Sequela of Prior Ankle Sprain ICD-10
• M24.272 : Disorder of ligament, left ankle • S93.412S : Sprain of calcaneofibular ligament of the left ankle, sequela
Ligamentous Laxity Documentation
ICD 9 Assessment: Ligamentous Laxity, Ankle
ICD 10 Assessment:
Ligamentous laxity, left ankle as a result of a calcaneofibular ligament sprain
Thank You!!
Documentation and ICD-10 Coding
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA
APMA Coding Committee
Expert Panelist, Codingline
APMA MACRA Task Force
Fellow, American Academy of Podiatric Practice Management
Board of Directors, ASPS
Board of Directors, APWCA
Twitter: @DrLehrman
Presenter
Presentation Notes
October 1, 2015 forgiveness
Resources • Fife, C.E., MD, FAAFP, CWS. The debridement dilemma
• National Government Services. National Government Services LCD for Debridement Services (L27373),http://apps.ngsmedicare.com/lcd/LCD_L27373.htm,
• Just Coding News. (August 8, 2012). Differentiate between types of wound debridement. JustCoding News: Outpatient
• Novitas Local Coverage Determination (LCD): Wound Care (L35139) https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35139&ver=40&CntrctrSelected=324*1&Cntrctr=324&s=45&DocType=Active&bc=AggAAAIAIAAAAA%3d%3d&
• Noridian Medicare, Wound care and debridement – Provided by physician, NPP or as incident-to services, https://www.noridianmedicare.com/cgi-bin/coranto/viewnews.cgi?id=EFFZFZyyEpAJGDJCxK&tmpl=part_a_viewnews&style=part_ab_viewnews