ICD-10-CM 2014 HISTORY & CODING CONVENTIONS. ICD-10 History The World Health Organization (WHO) adopted ICD-10 (International Classification of Diseases,

ICD-10-CM 2014HISTORY & CODING CONVENTIONS

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ICD-10 History

The World Health Organization (WHO) adopted ICD-10 (International Classification of Diseases, Tenth Revision) in 1990 and it came into use in 1994 by other countries.

The ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) was developed under the oversight of National Center for Health Statistics in 1997 and has undergone several modifications since then.

ICD-10-CM History and Updates

In the January 16, 2009 Federal Register the final rule was published to adopt the Medical Data Code Set to ICD-10-CM & ICD-10-PCS.

One last limited code update modification was made for October 2013.

Beginning in October 2014 , ICD-10-CM will have regular annual updates that will go into effect October 1st of each year.

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2014 ICD-10-CM is available at

http://www.cdc.gov/nchs/icd/icd10cm.htm or http://www.cms.hhs.gov/ICD10● 2014 ICD-10-CM Index to Diseases and Injuries● 2014 ICD-10-CM Tabular List of Diseases and Injuries

o Instructional Notations

● 2014 Official Guidelines for Coding and Reporting ● 2014 Table of Drugs and Chemicals● 2014 Neoplasm Table ● 2014 Mapping ICD-9-CM to ICD-10-CM and

ICD-10-CM to ICD-9-CM”

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ICD-10-CM Coding Guidelines

The guidelines are approved by four organizations:● American Hospital Association (AHA)● American Health Information Management Association

(AHIMA)● Centers for Medicare and Medicaid Services (CMS), and● National Center for Health Statistics (NCHS)

Coding Conventions and Guidelines

ICD-10-CM

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Organization & Structure Changes

21 Chapters

V and E codes incorporated into main ICD-10-CM Classification

Sense Organs (eyes and ears) have separate chapters

Updated terminology and code reassignment to more appropriate chapters

Injuries are classified by site and then type

Postoperative complication codes have been moved to body system

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Organization & Structure Changes -2

Alphanumeric – 3 to 7 digits

Addition of placeholder “X”

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New Features

Combination codes for condition and common manifestations

Combination codes for poisonings and external cause

Added laterality

Added 7th digit for episode of care

Expanded codes for: Injuries, diabetes, substance abuse, pressure ulcers and postoperative complications

Changes in time frames in certain codes

Added standard for two types of “excludes” notes

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General Equivalency Mapping (GEMS)

Mappings between ICD-9-CM and ICD-10-CM classification systems have been developed to facilitate the transition from one code set to another.

http://www.cdc.gov/nchs/icd/icd10cm.htm

General Equivalency Mapping (GEMS)

APPROPRIATE USE

Convert multiple databases from ICD-9-CM to ICD-10-CM

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INAPPROPRIATE USE

Crosswalks

There is not a one-to-one match between ICD-9-CM and ICD-10-CM codes, for a multitude of reasons (e.g., new concepts in ICD-10-CM, a single ICD-9-CM code may map to multiple ICD-10-CM codes).

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Coding in ICD-10-CMICD-9-CM ICD-10-CM

Three to five characters Three to seven characters

First digit is numeric but can be alpha (E or V)

First character always alpha

2–5 are numeric All letters used except U

Always at least three digits Character 2 always numeric: 3–7 can be alpha or numeric

Decimal placed after the first three characters (or with E codes, placed after the first four characters)

Always at least three digits

Alpha characters are not case-sensitive Decimal placed after the first three characters

Alpha characters are not case-sensitive

X X X X

Category

.Etiology, anatomic

site, severity

Added 7th character for obstetrics,

injuries, and external causes

of injury

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Coding and Seventh Character

X X XAMS 0 2 6. 5 x A

Additional Characters

Alpha (Except U)

2 Numeric3-7 Numeric or Alpha

3–7 Characters

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Alphabetic Index

The Alphabetic Index is divided into two parts:● The Index to Diseases and Injury● The Index to External Causes of Injury

Within the Index to Disease and Injury there is a Neoplasm Table and a Table of Drugs and Chemicals.

There is no Hypertension table.

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Alphabetic Index -2

Main terms in boldface font are listed in alphabetic order. Then, indented beneath the main term, any applicable subterm or essential modifier will be shown in alphabetical order. The indented subterm is always read in combination with the main term.

Pneumonia J18.9

aspiration J69.0

due to

food J69.0

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Alphabetic Index -3

Nonessential modifiers appear in parentheses ( ) and do not affect the code number assigned.

The “-” at end of an index entry indicates that additional characters are required.

Amblyopia (congenital) (ex anopsia) (partial) (suppression) H53.00-

deprivation H53.01-

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Alphabetic Index -4

Manifestation codes are included in the alphabetic index by including a second code, shown in brackets [ ] directly after the underlying or etiology code which should always be reported first.

Chorioretinitis – see also inflammation chorioretinal

Egyptian B76.9 [D63.8]

Histoplasmic B39.9 [H32]

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Tabular List

21 Chapters

Diseases of the Nervous System and Sense Organs now in three chapters: Nervous System, Eye and Ear

The order of chapters has changed

Within the chapters, category restructuring and code reorganization have occurred

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Tabular List -2

Chapters are subdivided into subchapters (blocks) that contain three character categories and form the foundation of the code.

Chapter 8 Diseases of the Ear and Mastoid Process (H60 – H95)

This chapter contains the following blocks:

H60 – H62 Disease of external earH65 – H75 Disease of middle ear and mastoidH80 – H83 Disease of inner earH90 – H94 Other disorders of ear

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Tabular List -3

Most but not all categories are further subdivided into four or five character subcategories, e.g. (I10 – Hypertension)

The fourth character when placed after the decimal point of:● 8 - (.8) is used to indicate “other specified”, and● 9 - (.9) is usually reserved for “unspecified”

K52.89 Other specified noninfective gastroenteritis and colitisK52.9 Noninfective gastroenteritis and colitis, unspecified

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Tabular List -4

(NEC) – “not elsewhere classified”

(NOS) – “not otherwise specified”

Both NEC and NOS have their own codes

Five and six character codes provider greater specificity or more information about the condition

Codes must be used to the highest number of characters available or to the highest level of specificity

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Tabular List -5

Certain categories have an additional seventh character extension. The extension must always be the seventh and final character. When the code contains fewer than seven characters, the place holder “X” must be used to fill the empty character(s).

S00.03XD Contusion of scalp, subsequent episode of care

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Tabular List Notes

Notes are located at the beginning of chapters or any subdivisions that follow and apply to all the categories within it.

Beginning of the chapter – R00-R99 Beginning of a subchapter – D37-D48

Q&A

ICD-10-CM History & Conventions

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Exercise #1

Which of the following is a true statement regarding ICD-10-CM codes?

a. No decimals are used.

b. The first character is always an alpha.

c. Consist of three to five characters.

d. The second and third characters are always

numeric. 

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Answer #1

b. Always a letter

Rationale: The first character of an ICD-10-CM code is always an alphabetic letter. All other statements are false because ICD-10-CM codes do have a decimal placed after the first three characters, the codes consist of three to seven characters, and the second is always numeric but the third character can be alpha or numeric.

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Exercise #2

True or false? The GEMs are a crosswalk between ICD-9-CM and ICD-10-CM.

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Answer #2

b. False

Rationale: The GEMs are not a crosswalk between ICD-9-CM and ICD-10-CM.

Coding and Use of Seventh Character

Injury

Either alpha or numeric

Placeholder X

Meanings vary

Injury - Identifies Injury● Initial – Receiving active treatment● Subsequent – Receiving routine care during healing or recovery

(after active treatment)● Sequela – Complications or conditions arising as result of a

condition

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Coding Convention Abbreviations

Not Elsewhere Classified “NEC” – A residual category, subdivision, or subclassification that provides a location for “other” types of specified conditions that have not been classified anywhere else in the code set. These residual codes may also contain the term “NEC” as part of their descriptor.

E87.8 Other Disorder of electrolyte and fluid balance, not elsewhere classified.

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Coding Convention Abbreviations -2

Not Otherwise Specified “NOS” - for use when the documentation of the condition identified by the provider is insufficient to assign a more specific code.

F03.90 Unspecified Dementia without behavioral disturbance – Dementia, NOSH65.9 Unspecified nonsuppurative otitis media Allergic otitis media NOS Exudative otitis media NOS Mucoid otitis media NOS

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Coding Conventions Punctuation

( ) Parentheses – supplemental words that may or may not be present.

[ ] - Brackets – synonyms, alternative workings or explanatory phrases.

I10 – Essential (primary) hypertension J00 – Acute nasopharygitis (common cold)

G72.41 Inclusion body myositis [IBM]S62.12 Fracture of lunate [semilunar]

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Coding Conventions Punctuation -2

Colon ( : ) – used after an incomplete term which needs one or more of the modifiers following the colon. Used in both “includes” and “excludes” notes in which the words that precede the colon are not considered complete terms and therefore must be appended by one of the modifiers indented under the statement.

G73.7 Myopathy in diseases classified elsewhereExcludes1: myopathy in:

rheumatoid arthritis (M05.32) sarcoidosis (D86.87)

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Coding Conventions Punctuation -3

Dashes ( - ) in the Alphabetic Index, dashes at the end of a code indicates an incomplete code

In the Tabular List, a dash preceded by a decimal point (.-) indicates an incomplete code

J43 EmphysemaExcludes 1: emphysematous (obstructive) bronchitis (J44.-)

Fracture, pathological ankle M84.47- carpus M84.44-

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Coding Convention Instructional Notes

Includes notes – used to clarify the condition included within a particular chapter, section, category, subcategory or code. They are not exhaustive and may include diagnoses not listed in the inclusion note. The word “includes” is not preceded by the list of terms at the code level.

K25 Gastric UlcerIncludes: erosion (acute) of stomach

pylorus ulcer (peptic) stomach ulcer (peptic)

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Coding Convention Instructional Notes -2

Excludes 1 – not coded here. Used when two codes cannot occur together.

G59 Mononeuropathy in disease classified elsewhere Excludes 1:

Diabetic mononeuropathy (E09 – E14 with .41) tuberculous mononeuropathy (A17.83)

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Coding Convention Instructional Notes -3

Excludes 2 – not included here. Used when the condition excluded is not part of the condition represented by the code, but a patient may have both conditions at the same time.

J01 Acute SinusitisExcludes 1 – Sinusitis NOS (J32.9)Excludes 2 – Chronic Sinusitis (J32.0 – J32.8)

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Coding ConventionsCode First & Use Additional Code

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. The underlying condition is sequenced first followed by the manifestation. The “use additional code” note appears at the etiology and a “code first” note at the manifestation code.

Coding ConventionsCode First & Use Additional Code -2

G30 Alzheimer’s disease Use additional code to identify:

dementia with behavioral disturbance (F02.81) dementia without behavioral disturbance (F02.80)

F02 Dementia in other diseases classified elsewhere Code first the underlying physiological condition, such as: Alzheimer’s (G30.-)

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Coding ConventionsCross Reference Notes

Cross reference notes are used in the Alphabetic Index to advise the coding professional to look elsewhere before assigning a code. There are three terms used: see, see also, see condition

Hemorrhage, cranial – see Hemorrhage, intracranialLabyrinthitis (circumscribed) (destructive) (diffuse) (inner ear) (latent) (purulent) (suppurative)– see also subcategory H83.0 Hematoma (traumatic) (skin surface intact) (see also Contusion)

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Coding ConventionsRelational Terms

And – should be interpreted to mean “and/or” when it appears in the code title within the Tabular List.

I80 Phlebitis and thrombophlebitis

I82 Other venous embolism and thrombosis

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Coding ConventionsRelational Terms -2

With – should be interpreted to mean “associated with” or “due to” when it appears in the code title, the Alphabetical Index, or an instructional note in the Tabular List. The term “with” in the Alphabetical Index is sequenced immediately following the main term, not in alphabetical order.

Asthma, asthmatic with chronic obstructive pulmonary disease J44.9J44 Other chronic obstructive pulmonary disease Includes asthma with chronic obstructive pulmonary disease

Careful Coding Required In ICD-10-CM, we are using number zero “0” and

capital letter “O”, number one “1” and capital letter “I”

They look very similar, so input and document these numbers and letters carefully!

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General Coding GuidelinesI.C.B.1. Locating a code in ICD-10-CM

Convention General Coding Guidelines and Chapter Specific

Refer to the ICD-10 Section/Convention General Coding Guidelines and chapter specific

Example: ● I.C.B.1 = Locating a code in ICD-10-CM

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General Coding GuidelinesI.C.B.1. Locating a code in ICD-10-CM

Locate the term in the Alphabetical Index

Verify the code in the Tabular Index

Read and be guided by the instructional notes in both indexes● The Alphabetical Index does not always provide the full code.

Laterality and 7th digit selection can only be done using the Tabular Index. The Alphabetical Index does not always indicate a dash

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General Coding GuidelinesI.C.B.2. Level of Detail in Coding

Codes are to be reported at their highest number of characters available

There are 3, 4, 5, 6 and 7 character codes

A code is invalid if it has not been coded to the fullest number of characters required for that code, including the 7th character applicable

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General Coding GuidelinesI.C.B.3. Codes A00.0-T88.9, Z00-Z99.8

The appropriate code or codes from A00.0 – T88.9 and Z00 – Z99.8 must be used to identify diagnoses, symptoms, conditions, problems, complaints or other reason(s) for the encounter/visit

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General Coding GuidelinesI.C.B.4. Signs and Symptoms

Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider

Chapter R00 – R99 Symptoms, Signs and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified contains many, but not all codes for symptoms

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General Coding GuidelinesI.C.B.5. Integral Part of a Disease

Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.

Examples:Altered Mental Status due to UTI - N39.0COPD with Shortness of Breath - J44.9

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General Coding GuidelinesI.C.B.6. Not an Integral Part of Disease -2

Signs and symptoms that may not be associated routinely with a disease process should be coded when present.

Resident has a culture that returned difficile. The resident has diarrhea with additional symptoms of malaise, low-grade fever and frequent diarrhea. The resident was started on Flagyl. The resident is weak, dehydrated, and needs IV fluids.

Infection, Clostridium, difficile, food borne (disease) A04.7 Dehydration E86.0

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General Coding GuidelinesI.C.B.7. Multiple Coding

In addition to the etiology/manifestation convention that requires two codes, there are other single conditions that also require more than one code. See “Use additional code” notes in the Tabular List at the code level. These are sequenced secondary to the condition code.

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General Coding GuidelinesI.C.B.7. Multiple Coding -2

“Code first” notes are under certain codes that are not specifically manifestation codes but may be due to an underlying cause. When there is a “code first” note and an underlying condition is present, the underlying condition is sequenced first.

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General Coding GuidelinesI.C.B.7. Multiple Coding -3

“Code if applicable, any causal condition” notes indicate that this code may be assigned as a principal diagnosis when the causal condition is unknown or not applicable.

If the causal condition is known, then the code for that condition should be sequenced as the principal diagnosis or first-listed diagnosis.

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General Coding GuidelinesMultiple Coding Example

Multiple codes may be needed for sequela conditions. See Guideline #10.

E. coli urinary tract infection

Infection, Urinary (tract) N39.0 Use additional code (B95-B97), to identify infectious

agentInfection, bacterial, Escherichia coli [E. coli] (see also Escherichia coli) B96.20

General Coding GuidelinesI.C.B.8. Acute and Chronic Conditions

If the same condition is described as both acute (subacute) and chronic and separate subentries exist in the Alphabetic Index at the same indention level, code both and sequence the acute (subacute) code first

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Acute and chronic bronchitisBronchitis, acute or subacute (with bronchospasm or obstruction) J20.9Bronchitis, chronic J42

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General Coding GuidelinesI.C.B.9. Combination Code

A combination code is a single code used to classify:● A diagnosis with an associated secondary manifestation, or● E11.69 Type 2 diabetes with other specified complication

Use additional code to identify complication

● A diagnosis with an associated complication J44.0 Acute Bronchitis with COPD

See Combination codes for poisonings (accidental, intentional self-harm, assault, undetermined)

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General Coding GuidelinesI.C.B.9. Combination Code -2

Assign only the combination code that fully identifies the diagnostic conditions involved or when directed by the Alphabetical Index

Multiple coding should not be used when the classification provides a combination code that clearly identifies all the elements documented in the diagnosis

When a combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code

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General Coding GuidelinesI.C.B.10. Sequela

“A residual effect (condition produced) after the acute phase of an illness or injury has terminated.”

There is no time limit for the sequela code

The residual may be apparent early or years later

Generally requires two codes:● The condition or nature of the sequela – first

I69.16 Other paralytic syndrome following intracerebral hemorrhage

● The sequela code – second G82.5- Quadriplegia

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General Coding GuidelinesI.C.B.10 Sequela

Exception to above guideline.● In instances where the code for the sequela is followed by a

manifestation code identified in the Tabular List and title, or the sequela code has been expanded at the 4th, 5th, or 6th character level to include the manifestation. (I69 Sequela of Cerebrovascular Disease)

● The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.

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General Coding GuidelinesI.C.B.12. Reporting Same Dx More than 1x

Each unique ICD-10-CM code may be reported only once for an encounter

This applies to bilateral conditions when there are no distinct codes for laterality or two different conditions classified to the same ICD-10-CM diagnosis code

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General Coding GuidelinesI.C.B.13. Laterality

Laterality Guidelines● For bilateral sites, the final character of the codes indicates

laterality.● An unspecified site code is also provided should the side not be

identified in the medical record.● If no bilateral code is provided and the condition is bilateral,

assign separate codes for both the left and right side

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General Coding GuidelinesI.C.B.14. Documentation of BMI andPressure Ulcer Stages Body Mass Index (BMI) and pressure ulcer stage codes

may be based on the medical record documentation from clinicians who are not the patient’s provider, such as a dietician for BMI or licensed nurse for pressure ulcer staging.

Associated conditions (overweight, obesity, or pressure ulcer) must be documented by the patient’s provider. If there is conflicting medical record documentation, either from the same clinician or different clinicians, the patient’s attending provider should be queried for clarification.

General Coding GuidelinesI.C.B.15. Syndromes

Follow the Alphabetical Index for guidance when coding syndromes

If there is no guidance in the Alphabetical Index assign codes for the documented manifestations of the syndrome

Look for the syndrome by its name in the alphabetical index first and then if not there, under syndrome

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Coding GuidelinesI.C.B.16. Complications

“Code assignment is based on the provider's documentation of the relationship between the condition and the care or procedure.”

The guideline extends to any complications of care, regardless of the chapter the code is located in.

Note: not all conditions that occur during or following medical care or surgery are classified as complications.

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Coding GuidelinesI.C.B.16. Complications -2

There must be a cause-and-effect relationship between the care provided and the condition, and an indication in the documentation that it is a complication. If the complication is not clearly documented, query the provider for clarification.

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Q&A

ICD-10-CM Coding Conventions and

Coding Guidelines

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Exercise #1

The ICD-10-CM code for infection and inflammatory reaction due to other internal orthopedic prosthetic device, implant or graft is T84.7 and requires the use of a seventh character to identify the encounter. Which of the following is the correct code for a subsequent encounter?a. T84.7Db. T84.7XDc. T84.7XXDd. T84.7

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Answer #1

Answer: c. T84.7XXD

Rationale: ICD-10-CM Coding Guideline I.A.5 states that the seventh character must always be the seventh character in the data field. If a code that requires a seventh character is not six characters long, a placeholder X must be used to fill in the empty characters. Additionally, Guideline A.4 indicates that ICD-10-CM utilizes a placeholder character X and where a placeholder exists, the X must be used in order for the code to be considered a valid code. All alpha characters in ICD-10-CM are not case sensitive, which means that if the placeholder X is entered in either the upper- or lowercase format, the meaning would not change.

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Exercise #2

True or false? When the term “and” is used in a narrative statement it is interpreted to mean only “and.”

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Answer #2

Answer: False

Rationale: The word “and” should be interpreted to mean either “and” or “or” when it is used in a narrative statement (ICD-10-CM Coding Guideline I.A.8).

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Exercise #3

True or false? In ICD-10-CM all inclusion notes contain all conditions for which a particular code number is to be used and are considered to be “exhaustive.”

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Answer #3

Answer: False

Rationale: Inclusion notes contain terms that are the condition for which that code number is to be used. The terms may be synonyms of the code title, or in the case of “other specified” codes, the terms are a list of various conditions assigned to that code. The inclusion terms are not necessarily exhaustive (ICD-10-CM Coding Guideline I.A.11).

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Exercise #4

True or false? When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together.

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Answer #4

Answer: True

Rationale: An Excludes2 note indicates that the condition excluded is not part of the condition represented, but a patient may have both conditions at the same time. When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together if the documentation indicates that the patient has both conditions (ICD-10-CM Coding Guideline I.A.12.b).

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Exercise #5

True or false? In ICD-10-CM a “code also” note provides sequencing guidance to the coding professional.

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Answer #5

Answer: False

Rationale: ICD-10-CM Coding Guideline I.A.17 states a “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction. In contrast, the “code first” and “use additional code” notes provide sequencing order of the codes.

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Exercise #6

True or false? A causal relationship can be assumed in a patient with both coronary atherosclerosis and angina pectoris and thus, the appropriate combination code should be assigned.

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Answer #6

Answer: True

Rationale: ICD-10-CM has combination codes for atherosclerotic heart disease with angina pectoris. The subcategories for these codes are I25.11, Atherosclerotic heart disease of native coronary artery with angina pectoris and I25.7, Atherosclerosis of coronary artery bypass graft(s) and coronary artery of transplanted heart with angina pectoris. When using one of these combination codes it is not necessary to use an additional code for the angina pectoris.

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Answer #6 -2

Rationale:…A causal relationship can be assumed in a patient with both atherosclerosis and angina pectoris unless the documentation indicates the angina is due to something other than the atherosclerosis (ICD-10-CM Coding Guideline I.C.9.b).