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Thursday, November 17, 2011

ICD 10 Coding: Revolutionary Change in Medicine for 2013

This is a lecture I gave yesterday to my office on ICD10 Coding. This will revolutionize medical documentation in 2 years. I had been assigned/volunteered to give this lecture. I am hopeful some of my readers in medicine will gain from this. Rich I also wanted to prove that I have not been goofing off, but I am also looking to get my mojo back on the basketball court.

100 Points on ICD 10 Coding
by Richard L Blake, DPM

Starts 10.1.13 Only Applies to ICD, not CPT
Outpatient billing DOS 10.1.13
Inpatient billing starts date of discharge 10.1.13 or later
No Grace Period

Facts: I. Greater Specificity and clinical accuracy make ICD 10 easier to use than ICD 9
2. Because ICD 10 is much more specific, is more clinically accurate, and uses a more
logical structure, it is much easier to use than ICD 10.

3 to 7 characters in the new coding system
First Alpha (only U not used)
Second Numeric
Rest Either
X can be used as placeholder
A code that needs 7 characters is invalid without all 7
All codes are invalid if not correct number of characters
In codes longer than 3 characters, the decimal after the 3rd character
Alpha is not case sensitive
7th character used in certain chapters (obstetrics, musculoskeletal, injuries, and external
causes of injury)

Examples Of Codes

ICD 10 book divided Alphabet Index and Tabular List (must use both)
Alphabetical Index (not based on anatomy)
Index is divided into 2 parts: Index to Diseases and Injuries and Index to External Causes
3, 4, 5, or 6 characters with or without dash (-) The dash tells us if more characters are
Look for the dash.

Tabular List (based on anatomy)
Tabular List is subdivided into categories (first 3 characters), subcategories (4th and 5th
characters), and codes (3rd through 7th characters).
3 Character categories. Examples :
S90-S99 Foot/Ankle Injuries
R25-R29 Symptoms and Signs nerves and
R50-R69 General Symptoms and Signs

There are some categories that stand alone as legitimate codes.
Decimal always after these first 3 characters
4th and 5th increase specificity
5th and 6th Laterality
7th about visit itself

[ ] Brackets used in Tab List identify manifestation codes
( ) Parenthesis is non essential information
: Colon in Tab List signifies code needs more characters

Some Differences from ICD 9:
Laterality (side of the body affected) has been added to relevant codes
Expanded use of combination codes (certain conditions and associated common symptoms
or manifestations
Injuries grouped by anatomical site rather than type of injury
Codes reflect modern medicine and updated medical terminology

How to Code? First look up diagnostic terms in Alphabet, then verify in Tab. Read and
follow guidance given. Laterality and 7th character only in Tab. A dash (-) in Alphabet indicates
more characters needed. Even no (-) Tab to tell you if 7th character is needed.
5th or 6th character for Laterality
1 right
2 left
0 or 9 unspecified in the chart

Example of Laterality
C50.511 Malignant neoplasm of lower outer quadrant of right female breast
C50.512 Malignant neoplasm of lower outer quadrant of left female breast
C50.519 Malignant neoplasm of lower outer quadrant of unspecified female breast

First: Report Code most responsible for the visit
Second: List Subsequent codes for co-existing conditions
Third: Code all documented conditions that exist, but not ones previously treated
and healed
Fourth: History codes if relevant are used Z80-Z87
Fifth: List Chronic diseases as long as applicable

Each code is reported once per encounter, even in bi lateral conditions, or in the situation where 2
conditions have the same code.
If the same condition is described in the medical note as both acute and chronic, and separate
entities exist in Alphabet, code both, with acute first.

Breakdown of Tab List
A/B Infections
C/D Neoplasms
D50-D89 Blood/Immune
E Endocrine/Metabolic
F Mental/Behavior
G Nervous
H Eye/Adnexa
I Circulation
J Respiratory
K Digestive
L Skin/SubQ
M Musculoskeletal /Connective Tissue
O Pregnancy/Childbirth
P Perinatal
Q Congenital
R Signs/Symptoms/Abnormal Tests and Findings
S/T Injury, Poisoning, External Causes
V External Causes of Morbidity
W Accidental Injuries
X Heat/Hot Substances
X92-Y09 Assault
Y21-Y99 Misc Causes of Morbidity
Z Factors Influencing Health Status

Before diagnosis established/confirmed, use symptoms and
signs, R codes.
If condition normally associated with the disease, do not need to code separately.

For Example:
Patient presents with pain and swelling on initial visit from gardening in the right knee.
The knee joint is too sore to adequately examine.
Since we can safely say she must have sprained her knee somehow, check Alphabet
under sprain , then knee, S83.9-
Then check Tab: S83.91x-
The x is a placeholder and the dash signifies I need a7th character. So, S83.91xA,
but this would be wrong!!!!!!!

Unless our PE is unbeatable, or we get an MRI on the first visit, we should use R codes until
diagnosis is solid.
R22.41 Localized swelling, mass and lump, right lower limb would work.
R52 Unspecified Pain would work
Neither of these require further specification and if you get an MRI soon the code
change would then reflect a more exact dx.
Since we found this patient could not bear weight, a secondary dx would be
Check Alphabet: difficulty, walking. R26.2
Check Tab: R26.2 is stand alone code ( has 2 excludes1 which can not be used with it)
Can we throw in Gardening, yes some of the Y codes work here. Y93.H2 Activity, gardening and

Diagnoses based on probable, suspected, rule out, etc does not
apply to outpatient coding.
In outpatient setting, first-listed diagnosis is used in lieu of principle
It may take 2 or 3 visits to establish diagnosis

So, on that gardener, so send her to PT with diagnostic codes R22.41 first-listed, R52 second,
R26.2 third, and Y93.H2. The therapy Rx will be designed to reduce the swelling while you await
approval for the MRI. Patients receiving Therapy only code chief diagnosis
first that is responsible for their visit. Other codes may be sequenced after.

When the MRI revealed torn posterior horn of the medial meniscus ,the Alphabet showed:
Injury,kneeS89.9- You are always supposed to check in Alphabet first.
Check Tab: search through S for exact dx S83.221A Peripheral Tear of Medial Meniscus, current
injury, right knee. The secondary dx of R26.2 still works. Gardening code also works. The swelling
code would not work since it is normally part of a torn meniscus diagnosis.

If we go back to our same gardener, when the Pre op is done the coding is Z01.81 Pre Op
Examination first with the reason for the surgery second
S83.221A (A should be okay since you are still working on the initial treatment )

During the Pre operative examination, an important history of past DVT was discovered, these
history codes can be found Z80-Z87. So, the 3rd code in the Pre op diagnosis
was Z86.71 Personal history of venous thrombosis and embolism. It should be listed since it
affects treatment.

Patients receiving Pre op only, sequence first a code from Z01.81. Describe a code for reason
surgery next. Code also any findings related to Pre op evaluation.
After surgery, Drs Susan Prieto and Victor Lewis were able to use their normal CPT codes since
they are not changing. The first post op visit again fell into the realm of Z codes Z47.89
Encounter for other orthopedic aftercare. And there are other more specific ones. Use the
reason for the surgery as the second code. For the aftercare of an injury, assign the acute injury
code (in this case S83.221-) with the 7th character D. S83.221D

Very Specific Coding: (many are used routinely in sports medicine)
Infectious Agents
Infections resistive to Antibiotics
Endocrine, nutritional, metabolic
Nervous System
Pressure Ulcers
MusculoSkeletal/Connective Tissue
Signs,symptoms, Abnormal clinical findings/lab findings
Orthopedic Aftercare in Z category with 100s other misc patient encounters

Musculoskeletal/Connective: M Codes
Most codes have site and Laterality
Site represents bone, joint, or muscle.
If more sites, multiple site code used. If need, use multiple codes when multiple site code absent.
If both bone and joint affected, use bone.
M codes: When to use them
Conditions from healed injury
Recurring conditions
Chronic conditions

Example: Osteoporosis Rules
Not Site specific (no injury at present) use M81 Category
If associated fracture, site must be identified
Z87.31 personal history of osteoporosis fracture should follow
M81 codes
M80 codes identify the site of the fracture
M80.08xA means initial visit age related pathological
fracture vertebra current

R codes: When to use them
Symptoms, signs, and abnormal clinical and lab,not elsewhere
classified R codes
Could be Ill-defined conditions
Acceptable before diagnosis established
Can be used after diagnosis code, if not normally associated
Special falling codes
R29.6 Repeated falls after recent fall
Z91.81 History of Falling (for at risk) when appropriate both used together
Special coding SIRS (systemic inflam response syndrome)

S Codes: When To Use Them
Current Acute Injury (see the example above of the torn meniscus)
Injuries S codes
Most with 7th character
A Initial Encounter. While receiving active treatment before the healing can begin
(may take multiple visits)
D Subsequent encounter. For routine care during healing/recovery phase
This is for cast changes, medication changes, other Follow up visits.
The aftercare Z codes are not to be used here.
S Sequela. For complications direct result of injury like ex scar after burn. You must use
both injury code and sequela code.S is added to the injury only. Sequela listed first,
than injury.
Assign separate codes for each injury, unless combination code exists.
Traumatic injury codes S00-T14.9 not for normal healing surgical wounds or surgical
Code for most serious injury first
Superficial injuries not coded if deeper injury at same site.
When primary injury also damages superficial nerves and blood vessels, code primary injury first.

Coding for Traumatic Fractures:
Fractures of multiple sites are to be coded individually.
If not indicated in the medical record, consider the fracture closed and displaced
7th Initial Encounter while active treatment even if delayed seeking treatment
A initial closed fracture
B initial open fracture
D subsequent encounter fracture normal healing
G subsequent encounter fracture delayed healing
K subsequent encounter fracture non union (also M and N)
P subsequent encounter fracture mal union (also Q and R)
S sequela
Multiple fractures should be sequenced for severity

Z Codes for patient encounters other than a disease or injury
Like Orthopedic Aftercare

More on Understanding the Lingo:
And means and/or
With means associated with or due to
See means another term must be looked at for the correct code to use
See Also not essential for coding
Both codes can never be used together
Indicates that the code identified in the medical record and code used by the physician can not
be reported together because the 2 conditions can not occur together

E10 Type 1 Diabetes Mellitus
Excludes1: diabetes mellitus due to underlining condition E08.-
drug or chemical induced diabetes mellitus E09.-
gestational diabetes O24.4-
hyperglycemia NOS R73.9
neonatal diabetes mellitus P70.2
type 2 diabetes mellitus E11.-

Another Example:
M21 Other Acquired deformities of limbs
Excludes1: acquired absence of limb Z89.-
congenital absence of limbs Q71-Q73
Both conditions may occur at same time, so both codes may then be used.
Indicates that condition identified in the medical record is not part of the condition
represented by the code used by the physician, so that both codes may be reported together
if the patient has both conditions

L89 Pressure Ulcer
Excludes2: diabetic ulcers (E08.621, E08.622, E09.621, E09.622, E10.621, E10.622,
E11.621, E11.622, E13.621, E13.622)
non pressure chronic ulcer of skin L97.-
skin infections L00-L08
varicose ulcer (I83.0, I83.2)

Another Example:
I70.2 Atherosclerosis of the native arteries of the extremities
Excludes2: atherosclerosis of bypass graft of extremities (I70.30-I70.79)
Other or other specified means specific code not exist
Unspecified codes med record not identify more specific
Inclusion Terms means conditions to use code but not exhaustive
Use Additional Code in Tab where another code could more fully describe condition. You
Must use when present, but you need to use last.
Default Code: code listed next to main term in Alphabet. Condition most connected to main
term. If med record not specify another term, use default.
Follow Alphabet guidance coding syndromes.

Code first/use additional code /in diseases classified elsewhere
Etiology codes must be first
Manifestation codes second
In diseases elsewhere means this is the manifestation code
In the Alphabet List, both codes listed together with manifestation codes in brackets.
Code Also
Two codes may be necessary/order discretionary

What is a combination code? Single code for 2 diagnoses, diagnosis with manifestation,
or diagnosis with complication. Combination codes are found in sub term entries Alphabet, and
reading inclusion and exclusion notes in Tab. They are to be used over multiple codes. Can also
be used with additional code.

Late Effects (sequela) after acute over. No time limit on reporting. Condition of late effect
coded first, late effect code second. Exceptions: when late effect code needs manifestation codes
(Tab), or has been expanded (-) to include manifestation. Code for acute phase never used with
late effect code.

Special coding at the time of discharge for impending or threatening conditions.
Nonspecific codes ( “unspecified” or “NOS” which is “not otherwise specified”) are
available to use when detailed documentation to support more specific code is not available.

ICD 10 Coding Examples:
Type 1 diabetics mellitus with diabetic nephropathy
First Check Alphabet:
Diabetes, diabetic (mellitus) (sugar) E11.9
type 1 E10.9
nephropathy E10.21
Then Verify in Tabular List:
E10 Type 1 diabetes mellitus
E10.2 Type 1 diabetes mellitus with kidney complications
E10.21 Type 1 diabetes mellitus with diabetic nephropathy

First Check Alphabet:
Hypertension, hypertensive (accelerated) (benign)
(essential) (idiopathic) (malignant) (systemic) I10
Verify Code in Tabular List:
E10 Essential (primary) hypertension
Includes: high blood pressure
Excludes1: hypertensive disease complicating pregnancy, childbirth, and
puerperium (O10-O11, O13-O16)
Excludes2: essential (primary) hypertension involving vessels of the brain
essential (primary) hypertension involving vessels of the eye

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.