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ICD-10 What Is It And Why Do I Care?


Title: Slide 1 Author: Daylaun Egusquiza Last modified by: Diagnosis Plus Created Date: 2/21/2002 4:34:32 AM Document presentation format: On-screen Show (4:3) – PowerPoint PPT presentation

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Title: ICD-10 What Is It And Why Do I Care?


ICD-10 What Is It And
Why Do I Care?

  • Presented by
  • Karen Kvarfordt, RHIA,
  • AHIMA Approved ICD-10-CM/PCS
    President, DiagnosisPlus, Inc.
  • 2015

ICD-10 Changes Everything!
  • It will change the way in which we document
    patient care in our medical records both in the
    hospital and in our physician practices.
  • Tell the patient story better!

  • WHO (World Health Organization) owns publishes
    ICD (International Classification of Diseases).
  • WHO endorsed ICD-10 in 1990 members began using
    ICD-10 or modifications in 1994.
  • United States is the only industrialized country
    not using ICD-10 for our coding reporting of
    diseases, illnesses, and injuries. Why?
  • What makes us so different?

Countries Using ICD-10 For Case Mix
  • United Kingdom (1995)
  • Denmark, Finland, Iceland, Norway, Sweden (1994
  • France (1997)
  • Australia (1998)
  • Belgium (1999)
  • Germany (2000)
  • Canada (2001) (30,000 diagnosis codes)
  • United States (2015)
  • (Reimbursement Case Mix)

What is ICD-10?
  • Currently the U.S. health care industry uses
    ICD-9-CM codes for identifying and reporting
    diagnoses and procedures.
  • ICD-10 will replace the existing ICD-9 code sets
    (diagnosis procedure) effective October 1,
  • ICD-10-CM Diagnosis codes
  • ICD-10-PCS Inpatient hospital procedure codes
  • No impact on CPT and/or HCPCS codes!
  • CPT and HCPCS codes will continue to be used for
    physician and outpatient services including
    physician hospital visits (Observation
    Inpatient) EM

ICD-10 Impact
  • ICD-10-CM (Diagnoses)
  • Will be used by all hospitals, providers,
    clinics, lab, radiology, psych, rehab, nursing
    homes, etc.
  • ICD-10-PCS (Procedures)
  • Will be used only for hospital claims for
    inpatient hospital procedures
  • CPT/HCPCS No change!
  • Procedures for Hospital Outpatients, Physician
    Visits, Lab and Radiology Outpatients, etc.

Why Should We Do ICD-10?
  • What is the benefit to the provider?
  • Greater specificity in identifying health
  • The greater level of detail in the new code sets
    will include laterality, severity and complexity
    of disease conditions, which will enable more
    precise identification and tracking of specific
  • Terminology and disease classification are now
    consistent with new technology and current
    clinical practice.

Additional Benefits
  • Share higher-quality data with other health care
  • ICD-10 increases the amount of specific
    information in every diagnosis code and makes
    this more valuable to other providers.
  • For example, ICD-9 has a code for laceration of a
  • ICD-10 lets you know if that laceration was of
    the index, little, middle, ring finger or thumb
    and if it was left, right, or bilateral.

  • Reimbursements will better align with activity
  • Payers will reimburse severe complex cases
    better and simple cases at lower rates.
  • How? By the diagnosis codes!

Heres an Example
  • Imagine you had a patient who was noncompliant
    with their medical therapy.
  • In ICD-9, the only code we have available is
    V15.81 (personal history of noncompliance with
    medical treatment).
  • Is the patient noncompliant because of their own
    personal reason? Or something else?

How Will it Look in ICD-10?
  • Z9111 (Patients noncompliance with dietary
  • Z91120 (Patient's intentional underdosing of
  • regimen due to financial
  • Z91128 (Patients intentional underdosing of
  • regimen for other reason)
  • Z91130 (Patients unintentional underdosing of
  • regimen due to age-related
  • Z91138 (Patients unintentional underdosing of
  • regimen for other reason)
  • Shows whether or not the patients noncompliance
    was intentional, but also identifies if the
    patient needs some form of assistance from social
    services, etc.

  • Diagnosis Coding
  • (ICD-10-CM)

  • Allows for greater specificity detail which
    is currently lacking in ICD-9-CM.
  • Moving from 14,025 ?69,823 diagnosis codes!
  • 25,000 (36) of all ICD-10-CM diagnosis codes
    will now distinguish right vs. left.
  • Must be documented in the medical record
  • for code capture.
  • Expanded of characters of the ICD-10-CM
    diagnosis codes will provide greater specificity
    to identify Etiology, Anatomical site,

Why Are There So Many New Codes?
  • Main difference between ICD-9-CM and ICD-10-CM
    codes, outside of structural changes, is the
    SPECIFICITY of the code.
  • ICD-10-CM diagnosis codes will range anywhere
    from 3 to 7 characters which will allow us to
    capture this greater detail.
  • But it must be documented in the record!

ICD-10 Documentation Concepts
  • Stage or grade of disease
  • Specific anatomical location
  • Acute vs. chronic
  • Severity mild, moderate, severe
  • Episode of care initial vs. subsequent vs.
  • Injuries, Fractures, Poisonings
  • Laterality right, left, or bilateral

ICD-9-CM vs. ICD-10-CM
  • ICD-9-CM
  • 3 - 5 digits or characters
  • 1st character is numeric or alpha (E or V codes)
  • 2nd 5th characters are numeric
  • Decimal placed after the first 3 characters
  • 17 Chapters and V E codes are
  • 14,025 diagnosis codes
  • ICD-10-CM
  • 3 - 7 digits or characters
  • 1st character is alpha (all letters used except
  • 2nd 7th characters can be alpha and/or numeric
  • Decimal placed after the first 3 characters (the
  • 21 Chapters and V E codes are not
  • 69,823 diagnosis codes

Level of Detail Example
  • ICD-9-CM (irregular astigmatism) (367.22)
  • Only 1 code currently in ICD-9-CM
  • ICD-10-CM (irregular astigmatism)
  • Will have four choices
  • H52.211 (irregular astigmatism, right eye)
  • H52.212 (irregular astigmatism, left eye)
  • H52.213 (irregular astigmatism, bilateral)
  • H52.219 (irregular astigmatism, unspecified eye)
  • Physicians are likely documenting laterality
    now, but coders arent looking for it.
  • One easy place to look for documentation

Biggest Change in ICD-10-CM
  • For bilateral sites, the final character of the
    codes in ICD-10-CM indicate laterality.
  • Right side is always character 1 (RT)
  • Left side is always character 2 (LT)
  • Bilateral code is always character 3 (RT LT)
  • But be careful! Not all codes will have a
    bilateral distinction, i.e., carpal tunnel,
  • Unspecified side code is also provided should
    the side not be documented in the medical record.
  • Did we just lose our specificity?

Diagnoses That Will Require Laterality
  • Joint pain
  • Joint effusion
  • Injuries
  • Fractures
  • Dislocations
  • Arthritis
  • Cerebral infarction
  • Extremity atherosclerosis
  • Pressure ulcers
  • Cancers, neoplasms (breast, lung, bones, etc.)

  • Seventh (7th) character identifies the patient
    encounter type, with A for the initial
    encounter, D for the subsequent encounter and
    S for sequela encounter.
  • Initial Patient is receiving active treatment
  • First time being seen for the injury, i.e., ER
    visit, surgery, evaluation by new physician
  • Subsequent Follow-up care
  • Sequela Complication of a previous injury

Examples of ICD-10-CM Emergency Room
  • I10 Essential (primary) hypertension
  • S01.02xA Laceration with foreign body of scalp,
    initial encounter
  • S01.02xD Laceration with foreign body of scalp,
    subsequent encounter
  • S02.2xxA Fracture of nasal bones, initial
    encounter for closed fracture
  • H65.01 Acute serous otitis media, right ear
  • H65.02 Acute serous otitis media, left ear
  • H65.03 Acute serous otitis media, bilateral

  • Procedure Coding
  • (ICD-10-PCS)

ICD-10-PCS Characters (Medical and Surgical
  • Root
  • Section Operation
    Approach Qualifier
  • Body
    Body Device
  • System

1 2 3 4 5 6 7
Dissect ICD-10-PCS Code
  • Endoscopic Esophageal Excision via Natural or
    Artificial Opening
  • ICD-9-CM 45.16 Esophagogastroduodenoscopy (EGD)
    with Closed Biopsy

0 D B 5 8 Z X
Section (Medical/Surgical) Body System (Gastro-intestinal) Root Operation (Excision) Body Part (Esophagus) Approach (Via natural or artificial opening endoscopic) Device (No Device) Qualifier (Diagnostic)
Heres Another Example
  • Extraction of Products of Conception, Low
  • Open Approach
  • ICD-9-CM 74.1 (Low Cervical Cesarean Section)

1 0 D 0 0 Z 1
Section (Obstetrics) Body System (Pregnancy) Root Operation (Extraction) Body Part (Products of Conception) Approach (Open) Device (No Device) Qualifier (Low Cervical)
  • Whats New In ICD-10?

  • Under ICD-10-CM diagnosis codes will be based on
    the stage of pregnancy
  • First trimester
  • Second trimester
  • Third trimester
  • Trimesters are counted from the first day of the
    last menstrual period, and defined as
  • First trimester Fewer than 14 weeks
  • Second trimester Fourteen weeks
  • Third trimester Twenty-eight weeks

Nicotine Dependence
  • ICD-10-CM contains a separate category for
    nicotine dependence with subcategories to
    identify the specific tobacco product and
    nicotine-induced disorder(s). For example
  • Cigarettes
  • Chewing tobacco
  • Cigar, etc.
  • ICD-9 has only one diagnosis code (305.1) for
    tobacco use disorder or tobacco dependence.

  • New diagnosis code in the ICD-10 world!
  • Identifies situations in which a patient has
    taken less of a medication than prescribed by the
    physician and captures those reason(s).
  • Must be documented in the record!
  • Financial
  • Non-compliance

Burns and Corrosions
  • Burn codes identify
  • Thermal burns, except for sunburns, that come
    from a heat source
  • Burns resulting from electricity and/or radiation
  • Addition of the term corrosion is new in
  • ICD-10-CM
  • Corrosions are burns due to chemicals

  • Physician Documentation

Top 10 Documentation Pearls
  1. Laterality (left vs. right)
  2. Stage of Care (initial or follow-up)
  3. Specific Diagnosis (acute vs. chronic)
  4. Specific Anatomy (specific bone in the hand)
  5. Associated and/or Related Conditions
  6. Cause of Injury (hit by baseball, fall)
  7. Documentation of Additional Symptoms or
  8. Dominant vs. Non-Dominant Side
  9. Tobacco Exposure or Use
  10. Gustilo-Anderson Scale

  • Documentation Tips
  • For Specific Diagnoses

GERD Documentation
  • ICD-10-CM will include 2 diagnosis codes but does
    not include the abbreviation GERD
  • K21.0 (Gastro-esophageal reflux disease with
  • K21.9 (Gastro-esophageal reflux disease without
  • Barretts now broken down
  • With or without ulcer
  • With or without dysplasia
  • Staging of dysplasia
  • Low grade
  • High grade

Digestive Ulcer
  • Documentation needs to include the specific
  • Gastric
  • Duodenal
  • Peptic
  • Gastrojejunal
  • Further specificity needs to identify
  • Acute or chronic
  • With hemorrhage
  • With perforation
  • With hemorrhage and perforation
  • Without mention of hemorrhage or perforation

Asthma Documentation
  • Document the Severity (3 levels)
  • Mild (more than two times per week)
  • Moderate (daily and may restrict physical
  • Severe (throughout the day with frequent severe
    attacks limiting the ability to breathe)
  • Clarify whether acute, chronic, intrinsic or
  • Specify exercise-induced or other forms
  • Specify when chronic state asthmatic bronchitis
    exists and when acute exacerbation occurs
  • Document tobacco exposure or history of

Congestive Heart Failure
  • Documentation in ICD-10-CM needs to identify
    whether the CHF is acute or chronic and the
    specific type of heart failure
  • Combined systolic diastolic
  • Diastolic
  • Systolic
  • Left ventricular

  • Need to include specificity such as
  • Acute or subacute
  • Further specify with bronchiectasis, COPD, etc.
  • Allergic
  • Asthmatic
  • Chronic
  • Obstructive
  • Viral

Diabetes Mellitus
  • ICD-9 features 59 codes for diabetes, while
    ICD-10 offers more than 259 and adds a provision
    of poorly controlled to categories of
    controlled or not controlled.
  • Diabetes mellitus codes expanded to include the
    classification of the diabetes AND the
  • Needs to be clearly documented in the record!

More on Diabetes
  • Identify Type 1, Type 2, due to other secondary
    cause, i.e., gestational, etc.
  • In Type 2 or secondary cause, identify when using
    insulin long-term.
  • Identify all body systems affected by the
    diabetes, i.e., neuropathy and its manifestation,
    retinopathy and proliferative or
    nonproliferative, nephropathy and stage of CKD,
    vasculopathy, etc.
  • Identify all manifestations, i.e., ulcer, coma,
    gangrene, osteomyelitis, etc.

Chest Pain
  • Medical record documentation must include the
    specific location of the chest pain
  • Anterior wall
  • Atypical
  • Intercostal
  • Musculoskeletal
  • Non-cardiac
  • Precordial

Fracture Documentation
  • Documentation will need to include the following
  • to accurately code a fracture in ICD-10-CM
  • Displaced or non-displaced
  • Open or closed
  • Laterality (left vs. right vs. bilateral)
  • Specific bone and location of the bone
  • Distal, proximal, mid-shaft, etc.
  • Type of Encounter
  • Initial, subsequent, sequela

Fracture Subsequent Encounter
  • Subsequent encounter for open and closed
  • Used for encounters after active fracture
    treatment has been completed and the patient is
    receiving routine care during the healing or
    recovery period.
  • Closed Fracture 7th Character Extensions
  • D ? Routine healing or aftercare
  • G ? Delayed healing
  • K ? Nonunion
  • P ? Malunion

What is Gustilo-Anderson Scale?
  • Gustilo-Anderson classification identifies the
    severity of soft tissue damage in open
    fractures may be new to coders and physicians
  • Type I Wound is smaller than 1 cm, clean, and
    generally caused by a fracture fragment that
    pierces the skin (low energy injury)
  • Type II Wound is longer than 1 cm, not
    contaminated, and w/o major soft tissue damage or
    defect (low energy injury)
  • Type III Wound is longer than 1 cm, with
    significant soft tissue disruption. The
    mechanism often involves high-energy trauma,
    resulting in a severely unstable fracture with
    varying degrees of fragmentation.

  • Specify location, i.e., inguinal, femoral,
    umbilical, ventral, diaphragmatic all other
    abdominal hernias default to other, etc.
  • Specify unilateral (which side) or bilateral
  • Specify with obstruction when present
  • Specify with gangrene when present
  • Specify when recurrent hernia (defaults to

Malignancy Example
  • Malignant Neoplasm Breast
  • 54 choices for male/female breast
  • Documentation must include
  • Laterality
  • Location (site)
  • Use of an additional code to identify estrogen
    receptor status
  • Example C50.422 (Malignant neoplasm of
    upper-outer quadrant of the left male breast)

And Another
  • Malignant Neoplasm Lung/Bronchus
  • 63 choices available in ICD-10-CM
  • Documentation must include
  • Specific site/location
  • Hilus, lingula, main bronchus, lower lobe, middle
    lobe, upper lobe, etc.
  • Example C34.2 (malignant neoplasm of middle
    lobe, bronchus or lung)
  • Laterality
  • Tobacco exposure or use (secondary diagnosis)

Physician Practices
  • ICD-10-CM diagnosis codes will impact every
    physician practice large or small!
  • Look at all areas that will impact your practice
    and identify each one that will be affected
  • Practice Management System
  • Electronic Medical Record (EMR)
  • Paper record
  • Superbill/encounter form does it have diagnosis
    codes on it?
  • Lab requisitions/orders

Task Is Not As Huge As It Appears!
  • Although the coding book is huge, many
    physician practices use only a small set or of
    diagnosis codes.
  • Start developing crosswalks between ICD-9-CM
    ICD-10-CM codes you use most frequently in the

  • Thats ICD-10!

  • Contact Info
  • Karen Kvarfordt, RHIA, CCS-P, CCDS
  • AHIMA Approved ICD-10-CM/PCS Trainer
  • President, DiagnosisPlus, Inc.
  • PO Box 486
  • Pocatello, ID 83204
  • (208) 221-5486
  • diagnosisplus1_at_live.com
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