ICD-10 Ready or Not here it comes! Coding

ICD-10 Ready or Not here it comes! Coding

ICD-10 Ready or Not here it comes! Coding & Clinical Documentation Class Presented by: Kathryn Melton- SIP and John Hailes- SMF September 23, 2015 Countdown to ICD-10 Implementation Sutter Independent Physicians

ICD-10 8 days to go!!! Compliance date: October 1, 2015 The Nation switches from ICD-9 to ICD-10 coding for medical diagnosis and inpatient hospital procedures No grace period for Medicare, SIP or any other organization Sutter Independent Physicians ICD-10 Claim Submissions

A valid ICD-10 code will be required on all claims for diagnosis reporting with dates of service, or dates of discharge for inpatients, that occur on or after 10/1/2015 ICD-10 codes will be rejected if submitted prior to 10/1/2015 SIP processing systems are not able to accept the new codes prior to the compliance date. No combo diagnosis coding Mixed reporting of both ICD-9 and ICD-10 codes will be rejected. Sutter Independent Physicians ICD-10

Importance of Documentation Will require greater detail for medical conditions Acuity, Disease Type, Laterality (Left, Right, Bilateral), Disease Stage Documentation must support the assignment of codes No assumption with coding If it is not documented, it did not happen Compliance Good documentation practice protects you from penalties and audit reviews RAF- Risk Adjustment Factor CMS reimburses Medicare Advantage plans based on patients health status RAF data is pulled from diagnosis on claims and medical records

documentation Sutter Independent Physicians ICD-10 Resources & Provider Support CMS Road to 10- www.roadto10.org

Training videos, common ICD-10 codes by specialty Clinical documentation tips Clinical scenarios Noridian JE Part B- ICD-10 Web-based workshop September 24, 2015 and October 22, 2015 www.noridianmedicare.com Sutter Independent Physicians ICD-10 ICD-10 Update on RAF

CMS list of ICD-10-CM diagnosis codes for the CMSHierarchical Condition Category (HCC) risk adjustment model: https://www.cms.gov/Medicare/Health-Plans/MedicareAdvtgSp ecRateStats/Risk-Adjustors-Items/IDC10Mappings.html?DLPa ge=1&DLEntries=10&DLSort=0&DLSortDir=descending Sutter Independent Physicians ICD-10 Optum 2015 WebEx Training These classes are FREE to Providers, Coders, Billers and Office Staff California Training Sessions Intro to ICD-10-CM and Coding for Risk Adjustment -1.5 Hours

ICD-10-CM training will include emphasis on clinical documentation improvement and compares coding in ICD-9-CM and ICD-10-CM for chronic conditions such as Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Hypertensive Diseases (CKD and Heart Failure [HF]), and Peripheral Arterial Disease (PAD). National Training Sessions Specialty Presentations-1 hour Content will include both ICD-9-CM and ICD-10-CM coding and documenting for Medicare Advantage. Specialties covered: Pulmonary Diseases Peripheral Vascular Diseases Diabetes Space is limited! To register contact Kathryn at [email protected]

Sutter Independent Physicians ICD-10 Training American Academy of Professional Coders (AAPC)https://www.aapc.com/icd-10/ ICD-10 Training for Physicians, Coders and office staff ICD-9 to ICD-10 Crosswalks (by Specialty) Contemporary Forums- www.ICD10PREPNOW.COM in association with AAPC Live ICD-10-CM 2 day Boot Camp training sessions

Sutter Health ICD-10 Documentation Tips Clinical Documentation Improvement Keys to ICD-10 Clinical Documentation Documentation Tips Documentation Tips

Documentation Tips Documentation Tips Documentation Tips Documentation Tips Documentation Tips Procedure Documentation Tips

Procedure Documentation Tips Sutter Health ICD-10 Resources HealthStream: Pre-Test provides option to test out of further training if proficient in ICD-10 documentation concepts Specialty-specific modules and videos assigned based on your designated specialty Available both inside and outside of the Sutter

Network Logging in from outside of Sutter? You can VPN into the Physician Education Site at http://mysutter/Resources/ICD10. You have already been assigned HealthStream courses based on your specialty. To access your HealthStream courses use your network login. (Your password will be your last name, all lowercase.) To access HealthStream from outside the network, click here: www.healthstream.com/hlc/sutterhealth Documentation Drives ICD-10 John Hailes ASC-E/M, CCS, CCS-P, CPC, CPC-H, CIRCC, CPMA, CPCI, CEMC, CFPC, Certified @ICD-10-CM/PCS Trainer

23 Objectives Identify areas in ICD-10-CM that include new terminology for clinical documentation Define areas in ICD-10-CM that enable improved data capture if more specific conditions are documented Acuity Disease type Site specifity

Disease stage Show providers examples of the type of terminology needed to show. stage, status, exacerbation, relapse and other qualifiers for conditions that can vary widely in their acuity and severity Top Clinical Documentation Issues for ICD10CM1010CMCM Expanded anatomy specificity requirements in high volume diseases Extensive code categories that combine the

underlying cause with manifestations or complications for many common acute and chronic diseases Increased numbers of codes that identify both the infective cause or agent and the specific state of the infectious disease diagnosis Documentation Matters If it was not documented, it was not done 26

Documentation Matters Impact of clinical documentation Patient Physician Facility Quality of care provided

Continuity of care Non-payment by Insurance Demonstrates accountability Performance Management Reduced or denied payment Relative Value Unit (RVU) Hierarchy Coding

Category (HCC) Coding and Billing Supporting documentation for treatment and services rendered Appropriate reimbursement DRG ICD-10 Code Build

Anatomical location Which anatomical structure Proximal, distal, medial, lateral, central, peripheral, superior, inferior, anterior, posterior Laterality Right side or left side

Severity Mild, moderate or severe Environmental factors Smoking 28

ICD-10 Code Build (cont.) Time parameters Intermittent/Paroxysmal Recurring Acute or chronic Post-op, post delivery Comorbidities or complications Diabetes with neuropathic joint Intracranial injury

Manifestations Paralysis Loss of consciousness Healing level Routing healing, delayed healing, non-union, malunion 29 Historical Clinician Education Findings and symptoms Fever

Hypoglycemia/hyperglycemia Wheezing External causes Motor vehicles, injury locations

Assault, accidental, work related, intentional self harm Type of encounter Initial encounter, subsequent encounter, encounter for condition sequela, routine evaluation 30 ICD- 9 VS. ICD-10 Coding and 7th Character

Extensions Alpha (Except U) M A XS X 0 X 2 Category 2 Numeric

3 - 7 Numeric or Alpha . Additional Characters X 6 X 5 Xx A

X Etiology, anatomic site, severity Added code extensions (7th character) for obstetrics, injuries, and external causes of injury 3 7 Characters

ICD-10 Big Picture 50% of all ICD-10 codes are related to the musculoskeletal system 36% of all ICD-10 codes distinguish right from left 25% of all ICD-10 codes are related to fractures 25% of the code increase is related to specification of encounter 1st trimester, 2nd trimester, 3rd Trimester 33 ICD- 10 Overview

34 Encounter Form 35 One More Example ICD-9-CM Sprained Ankle 5 Codes

ICD-10-CM Sprained Ankle 45 Codes Which part of the ankle was injured?

Right or Left? First-time Injury? 36 Non-Coronary Artery Arteriosclerosis ICD-9 440.XX Renal

Extremities Native/Graft ICD-10 I70.XXX More specific Sites Concept of laterality Other Specified site(s)

Right Left Bilateral Intermittent claudication Rest pain

Ulceration Gangrene 37 707.13 Ulcer of ankle, except pressure ulcer ICD-10-CM Codes L97.309 Non-pressure chronic ulcer of unspecified ankle with unspecified severity ** There are more specific code choice selections available in ICD-10-CM. These include: L97.301 Non-pressure chronic ulcer of unspecified ankle limited to breakdown of skin L97.302 Non-pressure chronic ulcer of unspecified ankle with fat layer exposed L97.303 Non-pressure chronic ulcer of unspecified ankle with necrosis of muscle L97.304 Non-pressure chronic ulcer of unspecified ankle with necrosis of bone

L97.309 Non-pressure chronic uler of unspecified ankle with unspecified severity L97.311 Non-pressure chronic ulcer of right ankle limited to breakdown of skin ** Code first any associated underlying condition: Atherosclerosis of the lower extremities (I70.23-, I70.24-, I70.33-, I70.34-, I70.43-, I70.44-, I70.53-, I70.54-, I70.63-, I70.64-, I70.73-, I70.74-) Chronic venous hypertension (I87.31-, I87.33-) Diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622, E11.621, E11.622, E13.621, E13.622) Postphlebetic syndrome (I87.01-, I87.03-) Postthrombotic syndrome (I87.01-, I87.03-) Varicose ulcer (I83.0-, I83.2-)

Code first any associated gangrene (I96) ICD-10-CM Grays Anatomy 1918 DISEASES OF THE CIRCULATORY SYSTEM 39 ICD-9-CM guidelines indicate that an MI is acute for 8 weeks, whereas ICD-10-CM

guidelines state 4 weeks. Type of hypertension not used as an axis Acute MI codes changed from 8 weeks to 4 weeks or less Grays Anatomy 1918

40 401.9 Hypertension (essential), unspecified ICD-10-CM Codes I10 Essential (primary) hypertension *Instructional note in ICD-10-CM indicates to use additional code to identify: exposure to environmental tobacco smoke (Z77.22) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17-)

tobacco use (Z72.0) Hypertension Essential (primary) hypertension I10 Type 1 Excludes hypertensive disease complicating pregnancy, childbirth and the puerperium (O10O11, O13-O16) Type 2 Excludes essential (primary) hypertension involving vessels of brain (I60-I69) essential (primary) hypertension involving vessels of eye (H35.0-) I11 Hypertensive heart disease

I11 Hypertensive heart disease I11.0 Hypertensive heart disease with heart failure I11.9 Hypertensive heart disease without heart failure Use Additional code to identify type of heart failure (I50) I50 Heart failure I50.20 Unspecified systolic (congestive) heart failure I50.21 Acute systolic (congestive) heart failure I50.22 Chronic systolic (congestive) heart failure

I50.23 Acute on chronic systolic (congestive) heart failure I50.30 Unspecified diastolic (congestive) heart failure I50.31 Acute diastolic (congestive) heart failure I50.32 Chronic diastolic (congestive) heart failure I50.33 Acute on chronic diastolic (congestive) heart failure I50.40 Unspecified combined systolic (congestive) and diastolic (congestive) heart I50.41 Acute combined systolic (congestive) and diastolic (congestive) heart failure I50.42 Chronic combined systolic (congestive) and diastolic (congestive) heart I50.43 Acute on chronic combined systolic (congestive) and diastolic (congestive)

I50.9 Heart failure, unspecified O10 Pre-existing hypertension complicating pregnancy, childbirth and the puerperium O10.0 Pre-existing essential hypertension complicating pregnancy, childbirth and the puerperium O10.01 Pre-existing essential hypertension complicating pregnancy, O10.011 first trimester O10.012 second trimester O10.013 third trimester O10.019 unspecified trimester O10.02 Pre-existing essential hypertension complicating childbirth

O10.03 Pre-existing essential hypertension complicating the puerperium O10.1 Pre-existing hypertensive heart disease complicating pregnancy, childbirth and the puerperium O10.11 Pre-existing hypertensive heart disease complicating pregnancy O10.111 first trimester O10.112 second trimester O10.113 third trimester O10.119 unspecified trimester O10.2 Pre-existing hypertensive chronic kidney disease complicating pregnancy, childbirth and the puerperium

O10.21 Pre-existing hypertensive chronic kidney disease complicating pregnancy O10.211 first trimester O10.212 second trimester O10.213 third trimester O10.219 unspecified trimester 427.31 Atrial fibrillation ICD-10-CM Codes I48.0 Paroxysmal atrial fibrillation I48.1 Persistent atrial fibrillation I48.2 Chronic atrial fibrillation

I48.91 Unspecified atrial fibrillation 427.0 Paroxysmal Supraventricular Tachycardia ICD-10-CM Codes I47.1 Supraventricular tachycardia *Instructional note in ICD-10-CM indicates to code first tachycardia complicating: abortion or ectopic or molar pregnancy (O00-O07, O08.8) obstetric surgery and procedures (O75.4) 427.89 Cardiac Dysrhythmias, other specified

ICD-10-CM Codes I49.8 Other specified cardiac arrhythmias *Instructional note in ICD-10-CM indicates to code first cardiac arrhythmia complicating: abortion or ectopic or molar pregnancy (O00-O07, O08.8) obstetric surgery and procedures (O75.4) 427.81 Sinoatrial Node Dysfunction ICD-10-CM Codes I49.5 Sick sinus syndrome *Instructional note in ICD-10-CM indicates to

code first cardiac arrhythmia complicating: abortion or ectopic or molar pregnancy (O00-O07, O08.8) obstetric surgery and procedures (O75.4) 414.01 Coronary athersclerosis of native coronary artery ICD-10-CM Codes I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris **Assign code from I25.110I25.119 when angina pectoris is present *Instructional note in ICD-10-CM indicates to use additional code, if applicable, to

identify coronary atherosclerosis due to lipid rich plaque (I25.83) Use additional code to identify: chronic total occlusion of coronary artery (I25.82) exposure to environmental tobacco smoke (Z77.22) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17-) tobacco use (Z72.0) AV Block 426.0 Atrioventricular block, complete I44.2 Atrioventricular block, complete

426.11 Atrioventricular block, first degree I44.0 Atrioventricular block, first degree 424.1 Aortic valve disorders ICD-10-CM Codes I35.9 Nonrheumatic aortic valve disorder, unspecified I35.0 Nonrheumatic aortic (valve) stenosis I35.1 Nonrheumatic aortic (valve) insufficiency I35.2 Nonrheumatic aortic (valve) stenosis with insuffisiciency I35.8 Other nonrheumatic aortic valve disorders

786.50 Chest pain, unspecified ICD-10-CMCodes R07.9 Chest pain, unspecified **There are more specific code choice selections available in ICD-10-CM. These include: R07.89 Other chest pain R07.2 Precordial pain R07.1 Chest pain on breathing R07.81 Pleurodynia Chapter

9 I21 Initial AMIs I22 Subsequent AMIs I23 Complication following STEMI and NSTEMI MI (within 28 day period) 55 410.40 Myocardial infarction, acute, of other inferior wall, episode of care unspecified

ICD-10-CM Codes I21.19 ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall *Instructional note in ICD-10-CM indicates to use additional code to identify: exposure to environmental tobacco smoke (Z77.22) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) status post administration of TPA in a different facility within the last 24 hours prior to admission to current facility (Z92.82) tobacco dependence (F17-) tobacco use (Z72.0)

Category I22 A code from category I22 must be used in conjunction with a code from category I21. Category I22 is never used alone. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. Chapter 9

57 ICD-10-CM ENDOCRINE, NUTRITIONAL AND METABOLIC DISEASES 58 ICD-10 versus ICD-9 59

Chapter 4 ICD-10 Diabetes Mellitus Combination codes No longer classified as controlled or uncontrolled Inadequately, out of control or poorly controlled coded by type with hyperglycemia 60

Diabetes mellitus ICD-10 Chapter 4 Combination codes No longer classified as controlled or uncontrolled Inadequately, out of control or poorly controlled coded by type with hyperglycemia

61 ICD-10 DM FORMAT Diabetes mellitus codes (DM) in ICD-10-CM are combination codes that include the (1) type of DM (2) the body system affected (3) the complication affecting that body system

62 ICD-10 DM Category E08 Diabetes mellitus due to underlying condition E09 Drug or chemical induced diabetes mellitus E10 Type 1 diabetes mellitus E11 Type 2 diabetes mellitus E13 Other specified diabetes mellitus 63

DM Add-ON Identify any insulin use (Z79.4) Poisoning due to drug or toxin, if applicable (T36-T65) Adverse effect, if applicable, to identify drug (T36-T50) 64 E08 Diabetes mellitus due to underlying condition

Code First the underlying condition, such as: Congenital rubella (P35.0) Cushing's syndrome (E24.-) Cystic fibrosis (E84.-) Malignant neoplasm (C00-C96) Malnutrition (E40-E46) Pancreatitis and other diseases of the pancreas ( K85-K86.-) 65 E09 Drug or Chemical induced diabetes mellitus

Code first (T36-T65) to identify drug or chemical Use additional code to identify any insulin use (Z79.4) 66 E10 Type 1 diabetes mellitus Type 1 Excludes diabetes mellitus due to underlying condition (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-)

hyperglycemia NOS (R73.9) neonatal diabetes mellitus (P70.2) postpancreatectomy diabetes mellitus (E13.-) postprocedural diabetes mellitus (E13.-) secondary diabetes mellitus NEC (E13.-) type 2 diabetes mellitus (E11.-) 67 E11 Type 2 diabetes mellitus Use additional code to identify any insulin use (Z79.4) Type 1 Excludes diabetes mellitus due to underlying condition (E08.-)

drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-) neonatal diabetes mellitus (P70.2) postpancreatectomy diabetes mellitus (E13.-) postprocedural diabetes mellitus (E13.-) secondary diabetes mellitus NEC (E13.-) type 1 diabetes mellitus (E10.-) 68 E13 Other specified diabetes mellitus

(specified type with) Use additional code to identify any insulin use (Z79.4) Type 1 Excludes diabetes (mellitus) due to autoimmune process (E10.-) diabetes (mellitus) due to immune mediated pancreatic islet beta-cell destruction (E10.-) diabetes mellitus due to underlying condition (E08.-) drug or chemical induced diabetes mellitus (E09.-) gestational diabetes (O24.4-) neonatal diabetes mellitus (P70.2) type 2 diabetes mellitus (E11.-) Includes

diabetes mellitus due to genetic defects of beta-cell function diabetes mellitus due to genetic defects in insulin action postpancreatectomy diabetes mellitus postprocedural diabetes mellitus secondary diabetes mellitus NEC 69 DM 4th Digit 0 = Hyperosmolarity usually complication of type 2 diabetes that involves extremely high blood sugar

(glucose) levels without the presence of ketones. Ketones are byproducts of fat breakdown 1 = Ketacidosis metabolic state associated with high concentrations of ketone bodies, formed by the breakdown of fatty acids and the deamination of amino acids (usually type 1) 2 = Nephropathy 3 = Opthalmic 4= Neurological 5 = Circulatory 6 = Other

70 2 = Nephropathy E08.2 Diabetes mellitus due to underlying condition with kidney complications E08.21Diabetes mellitus due to underlying condition with diabetic nephropathy E08.22Diabetes mellitus due to underlying condition with diabetic chronic kidney disease E08.29Diabetes mellitus due to underlying condition with other diabetic kidney

complication 71 3 = Opthalmic E08.31Diabetes mellitus due to underlying condition with unspecified diabetic retinopathy E08.311 with macular edema E08.319 without macular edema E08.32Diabetes mellitus due to underlying condition with mild nonproliferative diabetic retinopathy E08.321 with macular edema E08.329 without macular edema

E08.33Diabetes mellitus due to underlying condition with moderate nonproliferative diabetic retinopathy E08.331 with macular edema E08.339 without macular edema 72 3 = Opthalmic E08.34Diabetes mellitus due to underlying condition with severe nonproliferative diabetic retinopathy E08.341 with macular edema E08.349 without macular edema E08.35Diabetes mellitus due to underlying condition with proliferative diabetic

retinopathy E08.351 with macular edema E08.359 without macular edema E08.36Diabetes mellitus due to underlying condition with diabetic cataract E08.39Diabetes mellitus due to underlying condition with other diabetic ophthalmic complication 73 4= Neurological E08.4 Diabetes mellitus due to underlying condition with neurological

complications E08.40Diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified E08.41Diabetes mellitus due to underlying condition with diabetic mononeuropathy E08.42Diabetes mellitus due to underlying condition with diabetic polyneuropathy E08.43Diabetes mellitus due to underlying condition with diabetic autonomic (poly)neuropathy E08.44Diabetes mellitus due to underlying condition with diabetic amyotrophy E08.49Diabetes mellitus due to underlying condition with other diabetic

neurological complication 74 5 = Circulatory E08.5 Diabetes mellitus due to underlying condition with circulatory complications E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene E08.52Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene

E08.59Diabetes mellitus due to underlying condition with other circulatory complications 75 6 = Other E08.6 Diabetes mellitus due to underlying condition with other specified complications E08.61Diabetes mellitus due to underlying condition with diabetic arthropathy E08.610Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy

E08.618Diabetes mellitus due to underlying condition with other diabetic arthropathy E08.62Diabetes mellitus due to underlying condition with skin complications E08.620Diabetes mellitus due to underlying condition with diabetic dermatitis E08.621Diabetes mellitus due to underlying condition with foot ulcer E08.622Diabetes mellitus due to underlying condition with other skin ulcer E08.628Diabetes mellitus due to underlying condition with other skin complications 76 Examples of compliant documentation

1. Diabetic nephrosis, type 1 2. Secondary diabetes mellitus due to pancreatic malignancy, snowflake cataract 3. Type 1 diabetes with ketoacidosis 4. Diabetes mellitus, type 2 with hyperosmolar, nonketotic coma 5. CKD stage IV due to type 1 diabetes 6. Impotence due to diabetic peripheral neuropathy 7. Neonatal hypoglycemia 8. Hyperglycemic Type 1 diabetes mellitus with peripheral 77 vascular disease and gangrene of the right foot

ICD-10-CM PREGNANCY, CHILDBIRTH AND THE PUERPERIUM 78 Chapter 15 Trimesters 1

Less than 14 weeks 0 days 2nd 14 weeks 0 days to less than 28 weeks 0 days 3rd 28 weeks 0 days until delivery

st Trimester axis of classification rather than episode of care Not all conditions include codes for all three trimesters or is N/A Counted from first day of last menstrual period

79 Definitions Abortion vs. fetal death Chapter 15 20 weeks instead of 22 Early vs. late vomiting 20 weeks instead of 22

Preterm labor 37 completed weeks of gestation 80 7th Character Chapter 15 0 not applicable or unspecified

1 fetus 1 2 fetus 2 3- fetus 3 4 fetus 4 5 fetus 5 9 other fetus 81 Coding Note: The note at the beginning of Chapter 15 specifies the use of an additional code from

category Z3A, Weeks of gestation, to identify the specific week of the pregnancy. This is found in the alphabetic Index under Pregnancy, weeks of gestation. V72.31 Routine Gynecological Exam ICD-10-CM Codes Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings * Use additional code to identify abnormal findings Z01.419

Encounter for gynecological examination (general) (routine) without abnormal findings Instructional note under codes should be as follows: **Use additional code: for screening for human papillomavirus, if applicable (Z11.51) for screening vaginal pap smear, if applicable (Z12.72) to identify acquired absence of uterus, if applicable (Z90.71-) 626.2 Excessive Menstruation ICD-10-CM Codes N92.0 Excessive and frequent menstruation with regular cycle

N92.1 Excessive and frequent menstruation with irregular cycle N92.2 Excessive menstruation at puberty N92.4 Excessive bleeding in the premenopausal period 632 Missed Abortion ICD-10-CM Codes O02.1 Missed abortion ** Use additional code from category O08 to identify any associated complication ** An additional code from category Z3A is needed

to specify the weeks of gestation of the pregnancy. 616.10 Vaginitis and Vulvovaginitis, unspecified ICD-10-CM Codes N76.0 Acute vaginitis **Use additional code (B95-B97), to identify infectious agent There are other codes from this subcategory to describe vaginitis: N76.1 Subacute and chronic vaginitis N76.2 Acute vulvitis N76.3 Subacute and chronic vulvitis

N76.89 Other specified inflammation of vagina and vulva 626.4 Irregular menstrual cycle ICD-10-CM Codes N92.5 Other specified irregular menstruation N92.6 Irregular menstruation, unspecified * There are more specific code choice selections available in ICD-10CM. These include: N92.0 Excessive and frequent menstruation with regular cycle N92.1 Excessive and frequent menstruation with irregular cycle N92.2 Excessive menstruation at puberty N92.4 Excessive bleeding in the premenopausal period

Pediatrics Top 5 Diagnosis 1. 2. 3. 4. 5. V20.2 Routine infant or child health check 465.9 Acute upper respiratory infection 382.9 Unspecified otitis media 462 Acute pharyngitis 493.90 Asthma, unspecified type

V20.2 Routine infant or child health check

Z00.0 Encounter for general adult medical examination Z00.00 without abnormal findings Z00.01 with abnormal findings Z00.1 Encounter for newborn, infant and child health examinations

Z00.11 Newborn health examination Z00.110 Health examination for newborn under 8 days old Z00.111 Health examination for newborn 8 to 28 days old Z00.12 Encounter for routine child health examination Z00.121 with abnormal findings Z00.129 without abnormal findings Z00.2 Encounter for examination for period of rapid growth in childhood Z00.3 Encounter for examination for adolescent development state Z00.5 Encounter for examination of potential donor of organ and tissue Z00.6 Encounter for examination for normal comparison and control in clinical research program Z00.7 Encounter for examination for period of delayed growth in childhood Z00.70 without abnormal findings

Z00.71 with abnormal findings Otitis Media H65 Nonsuppurative otitis media H66 Suppurative and unspecified otitis media H67 Otitis media in diseases classified elsewhere 382.9 Unspecified Otitis Media H66.0 Acute suppurative otitis media H66.00 Acute suppurative otitis media without spontaneous rupture of ear drum

H66.001 right ear H66.002 left ear H66.003 bilateral H66.004 recurrent, right ear H66.005 recurrent, left ear H66.006 recurrent, bilateral H66.007 recurrent, unspecified ear H66.009 unspecified ear Upper Respiratory Infections

J00 Acute nasopharyngitis [common cold] J01 Acute sinusitis J02 Acute pharyngitis J03 Acute tonsillitis J04 Acute laryngitis and tracheitis J05 Acute obstructive laryngitis [croup] and epiglottitis

J06 Acute upper respiratory infections of multiple and unspecified sites 462 Acute Pharyngitis J02.0 Streptococcal pharyngitis J02.8 Acute pharyngitis due to other specified organisms J02.9 Acute pharyngitis, unspecified 465.9 Acute upper respiratory infection J06 Acute upper respiratory infections of multiple and unspecified sites

J06.0 Acute laryngopharyngitis J06.9 Acute upper respiratory infection, unspecified 462 Acute Pharyngitis J02.0 Streptococcal pharyngitis J02.8 Acute pharyngitis due to other specified organisms J02.9 Acute pharyngitis, unspecified Asthma ICD-9

493.XX 4th Digit Extrinsic Intrinsic Chronic Obstructive Other

ICD-10 J45.XXX Extrinsic Intrinsic Chronic Obstructive Other

5th Digit Exacerbation or status asthmatics 96 493.90 Asthma, unspecified type

J45 Asthma J45.2 Mild intermittent asthma J45.20 uncomplicated J45.21 with (acute) exacerbation J45.22 with status asthmaticus J45.3 Mild persistent asthma J45.30 uncomplicated J45.31 with (acute) exacerbation J45.32 with status asthmaticus J45.4 Moderate persistent asthma J45.40 uncomplicated

J45.41 with (acute) exacerbation J45.42 with status asthmaticus J45.5 Severe persistent asthma J45.50 uncomplicated J45.51 with (acute) exacerbation J45.52 with status asthmaticus 496 Chronic airway obstruction, not elsewhere classified ICD-10-CM Codes J44.9 Chronic obstructive pulmonary disease, unspecified ** There are more specific code choice selections available in ICD-10CM. These include: J44.0 Chronic obstructive pulmonary disease with acute lower

respiratory infection J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation ** Code also type of asthma, if applicable (J45.-) ** Use additional code to identify: Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Shortness of breath 786.05 Shortness of breath R06.02 Shortness of breath

786.09 Other dyspnea and respiratory abnormalities ICD-10-CM Codes R06.83 Snoring R06.3 Periodic breathing R06.4 Hyperventilation R06.00 Dyspnea, unspecified R06.89 Other abnormalities of breathing 466.0 Acute bronchitis ICD-10-CM Codes J20.9 Acute bronchitis, unspecified

** There are more specific code choice selections available in ICD-10CM. These include: J20.0 Acute bronchitis due to Mycoplasma pneumoniae J20.1 Acute bronchitis due to Hemophilus influenzae J20.2 Acute bronchitis due to streptococcus J20.3 Acute bronchitis due to coxsackievirus J20.4 Acute bronchitis due to parainfluenza virus J20.5 Acute bronchitis due to respiratory syncytial virus J20.6 Acute bronchitis due to rhinovirus J20.7 Acute bronchitis due to echovirus J20.8 Acute bronchitis due to other specified organisms ICD-10-CM

NEOPLASMS 102 Whats new in ICD-10-CM for Coding Neoplasms? Laterality Greater specificity (anatomical site) Greater Clarity (Acuity) 103

Examples - Laterality C34.31 Malignant neoplasm RIGHT main bronchus or lung C34.32 Malignant neoplasm LEFT main bronchus or lung C4A. 71 Merkel cell carcinoma of the RIGHT lower limb, including hip C4A.72 - Merkel cell carcinoma of the LEFT lower limb, including hip 104 Examples - Greater specificity in terms of

anatomical sites: C00.0 - Malignant neoplasm of external upper lip Malignant neoplasm of lipstick area of upper lip Malignant neoplasm of upper lip NOS Malignant neoplasm of vermilion border of upper lip C30.1 - Malignant neoplasm of middle ear Malignant neoplasm of antrum tympanicum Malignant neoplasm of auditory tube Malignant neoplasm of eustachian tube Malignant neoplasm of inner ear Malignant neoplasm of mastoid air cells

Malignant neoplasm of tympanic cavity 105 Some 1 to 1 Conversions C61 Malignant neoplasm of prostate Replaces 185 Malignant neoplasm of prostate D07.5 Carcinoma in situ of prostate 233.4 Carcinoma in situ of prostate 106

Other Skin ICD-9 702 Actinic keratosis ICD-9 702.9 SK ICD-9 706.2 Sebaceous Cyst L57.0 Actinic keratosis L82.0 Inflamed seborrheic keratosis OR L82.1 other

seborrheic keratosis L72.3 Sebaceous cyst 107 Breast Lump/Mass ICD-9 code 611.72 NOW N63 Unspecified lump in breast 108

Breast Cancer ICD-10 Malignant neoplasm breast 54 choices for male/female breast Documentation must include: Laterality Location Estrogen receptor status (when necessary) 109 Breast Neoplasms

110 +Estrogen receptor status (Z17) Code 1st malignant neoplasm of breast (C50.-) Z17.0 Estrogen receptor positive status [ER+] Z17.1 Estrogen receptor negative status [ER-] 111 ICD-10 Ophthalmic Codes

ICD-10 Ophthalmic Codes ICD-10 Cataract ICD-9-CM vs. ICD-10-CM Codes ICD-9-CM 365.83 for aqueous misdirection (malignant glaucoma) ICD-10-CM H40.83 for aqueous misdirection (malignant glaucoma) H40.831 Aqueous misdirection, right eye

H40.832 Aqueous misdirection, left eye H40.833 Aqueous misdirection, bilateral eyes H40.839 Aqueous misdirection, unspecified eye 115 Primary Care Most Common Codes ICD-9 to ICD-10 116 Primary Care Most Common Codes

ICD-9 to ICD-10 117 Primary Care Most Common Codes ICD-9 to ICD-10 118 Primary Care Most Common Codes ICD-9 to ICD-10

119 ICD-10 Resources CMS.gov provider resources link: http://www.cms.gov/Medicare/Coding/ICD10/ProviderResources.html CMS.gov provider implementation timelines and checklists link: http://www.cms.gov/Medicare/Coding/ICD10/ICD-10ImplementationTimelines.html CMS.gov ICD-10 basics for medical practices link: http://www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10_Basics_for_Medical_Practices_0604 13[1].pdf Hospital Association - AHA.org website link: http://www.ahaphysicianforum.org/webinar/2013/icd-10/index.shtml Specialized training resources (extra cost): American Health Information Association AHIMA.org and American Association

Professional Coders AAPC.com links: http://ahima.org/ContinuingEd/Campus/courseinfo/ICD10.aspx http://www.aapc.com/icd-10/ Coding Tipsheets - AHIMA.org and Californiahia.org links: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_049431.hcsp?dDocName=bok1_049431#c http://www.californiahia.org/icd-10-cmpcs American Medical Association AMA.org website links: http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding- billing-insurance/hipaahealth -insurance-portability-accountability-act/transaction-code-set- standards/icd10-code-set.page 120

Questions? Contact: Kathryn Melton CPC [email protected] (916) 731-7817 Visit www.sipadmin.org for upcoming coding classes and much more!

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