Official Coding Guidelines ICD-10-CM and PCS

1. Official Coding Guidelines ICD-10-CM and PCS Presented by: MONICA LEISCH, RHIA, CCS AHIMA Approved ICD-10 Trainer Director of Compliance / HIM Services Healthcare Cost Solutions, Inc. mleisch@hcsstat.com May, 2013

2. Disclaimer • This material is designed and provided to communicate information about clinical documentation, coding and compliance in an educational format and manner. • The author is not providing or offering legal advice but rather, practical and useful information and tools to achieve compliant results in the area of clinical documentation, data quality and coding. • Every reasonable effort has been taken to ensure that the educational information is accurate and useful. • Applying best practice solutions and achieving results will vary in each hospital or facility’s situation.

3. Introduction ICD-10-CM Official Guidelines for Coding and Reporting 2013 for Diagnoses and Procedures

4. Guidelines Defined The guidelines are a set of rules that have been developed to accompany and complement the official conventions and instructions provided within the ICD itself. • Developed by The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) • Based on the coding and sequencing instructions in the Tabular List and Alphabetic Index • Required under the Health Insurance Portability and Accountability Act (HIPAA)

5. CM vs PCS • ICD-10-CM (Clinical Modification) • Morbidity classification developed by the US • Classifies diagnoses and reason for visit • Applicable to all health care settings • Based on ICD-10 classification system published by WHO • ICD-10-PCS (Procedural Coding System) • Procedure classification published by the US • Classifies all procedures • Applicable to inpatient care setting only • No such system in the ICD-10 published by WHO

6. Cooperating Parties The guidelines have been approved by the four organizations that make up the Cooperating Parties: • American Hospital Association (AHA) • American Health Information Management Association (AHIMA) • The Federal Government represented by Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS)

7. Hierarchy In order of Precedence: • Coding Conventions of the ICD Classification • Official Coding Guidelines • All other, including Coding Clinic, LCDs, etc.

8. CM Organization CM guidelines are organized into sections: • Section I includes the structure and conventions of the classification and general guidelines • Section II includes guidelines for selection of principal diagnosis for non-outpatient settings • Section III includes guidelines for reporting additional diagnoses in non-outpatient settings. • Section IV is for outpatient coding and reporting

9. Excludes Notes ICD-10-CM ICD-10-CM has two types of excludes notes. a. Excludes 1 A type 1 Excludes note is a pure excludes note. It means “NOT CODED HERE!” An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note. An Excludes1 is used when two conditions cannot occur together, such as a congenital form versus an acquired form of the same condition. b. Excludes 2 A type 2 excludes note represents “Not included here”. An excludes2 note indicates that the condition excluded is not part of the condition represented by the code, 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, when appropriate.

10. Impending or Threatened Condition ICD-10-CM Impending or Threatened Condition listed at time of Discharge: If confirmed, code as confirmed diagnosis. If it did not occur, check Alphabetic Index for subentry for the term impending or threatened and use that code if listed. If no subentry, code the existing underlying condition(s) and not the condition described as impending or threatened

11. Laterality ICD-10-CM Laterality For bilateral sites, the final character of the codes in the ICD-10-CM indicates laterality. An unspecified side 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.

12. Late Effects/Sequela ICD-10-CM Late Effects (Sequela) A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a late effect code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Coding of late effects generally requires two codes sequenced in the following order: The condition or nature of the late effect is sequenced first. The late effect code is sequenced second. An exception to the above guidelines are those instances where the code for late effect is followed by a manifestation code identified in the Tabular List and title, or the late effect code has been expanded (at the fourth, fifth or sixth character levels) to include the manifestation(s). The code for the acute phase of an illness or injury that led to the late effect is never used with a code for the late effect.

13. BMI & Ulcers ICD-10-CM Documentation for BMI (Body Mass Index) and Ulcers for coding: Codes may be assigned from clinician, (non physician) documentation The provider responsible for the patient’s care must provide coordinating diagnosis When conflicting documentation is present, query the responsible provider BMI codes should only be secondary diagnosis codes

14. Signs, Symptoms ICD-10-CM 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 18 of ICD-10-CM, Symptoms, Signs, and Abnormal Clinical and Laboratory Findings, Not Elsewhere Classified (codes R00.0 - R99) contains many, but not all codes for symptoms.

15. Complication of Care ICD-10-CM Complications of care As with all procedural or post-procedural complications, code assignment is based on the provider’s documentation of the relationship between the condition and the procedure. Includes pain, and transplant complications, and information that complication codes that include the external cause, and complication of care codes within the body system chapters.

16. Borderline Diagnosis ICD-10-CM Borderline Diagnosis documented at Discharge: Coded as confirmed unless the classification provides a specific entry Borderline conditions are not uncertain conditions so no distinction between inpatient and outpatient settings. If documentation is unclear, query

17. Human Immunodeficiency Virus Infections ICD-10-CM HIV Related Condition: Principal diagnosis is B20, HIV disease followed by addition diagnosis codes for the HIV related condition(s) HIV Unrelated Condition: Code the unrelated condition first following by B20 Asymptomatic human immunodeficiency virus Z21 is used for: no documentation of symptoms HIV positive, known HIV, HIV test positive or similar Do not use if AIDS is documented, treated for HIV-related illness or described as having any condition(s) resulting from his/her HIV positive status (use B20 instead) Patients with inconclusive HIV serology: Assign R75, Inconclusive laboratory evidence of HIV for patients with inconclusive HIV serology, for patient without definitive diagnosis or manifestations of the illness Previously diagnosed HIV – related illness: Once a patient has developed an HIV related illness, assign B20 on every subsequent admission/encounter

18. Sepsis/Severe Sepsis and Septic Shock Sepsis, Severe Sepsis, and Septic Shock Sepsis: assign the appropriate code for the underlying systemic infection. Type of infection or causal organism is not further specified, assign code A41.9, Sepsis, unspecified. Do not assign a code from subcategory R65.2, Severe sepsis, unless severe sepsis or an associated acute organ dysfunction is documented. Negative or inconclusive blood cultures do not preclude a diagnosis of sepsis in patients with clinical evidence of the condition, however, query the provider ICD-10-CM

19. Septic Shock Septic shock: Code first the systemic infection, followed by code R65.21, Severe sepsis with septic shock or code T81.12, Post-procedural septic shock. Add codes for other acute organ dysfunctions. The code for septic shock cannot be assigned as a principal diagnosis. ICD-10-CM

20. Urosepsis Urosepsis Nonspecific term. not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification. ICD-10-CM

21. Sequencing of Sepsis If it is present on admission and meets principal diagnosis definition: not to be considered synonymous with sepsis. Has no default code in the Alphabetic Index. If used, the provider must be queried for clarification. ICD-10-CM

22. Sepsis/Severe Sepsis with Infections If sepsis is present with a localized infection: Sequence sepsis codes first List localized infections second If due to a post-procedural infection: Sequence the code for the post-procedural infection first List sepsis codes second If septic shock is documented, list second as well ICD-10-CM

23. Sepsis/Severe Sepsis with Non-infectious Process If sepsis is present with a non-infectious process: If the sepsis is due to the non-infectious process, list the non-infectious process first List the sepsis codes second If the non-infectious process leads to an infection with sepsis, the infection should be listed first Code for Systemic Inflammatory Response Syndrome (SIRS) of non-infectious origin is not needed ICD-10-CM

24. Death NOS Death NOS Code R99, Ill-defined and unknown cause of mortality, Use only, when an expired patient is brought to the ED other healthcare entity and is pronounced dead upon arrival Does not represent the discharge disposition of death. ICD-10-CM

25. NeoplasmsGeneral Guidelines ICD-10-CM A primary malignant neoplasm that overlaps two or more contiguous sites should be classified to subcategory/code .8 (‘overlapping lesion’), unless the combo is specifically indexed elsewhere. For multiple neoplasms of same site, not contiguous, assign codes for each Example: tumors in different quadrants of same breast

26. NeoplasmsGeneral Guidelines (cont.) ICD-10-CM Malignant neoplasms of ectopic tissue are to be coded to origin of mentioned site Example: ectopic pancreatic malignant neoplasms are coded to pancreas, unspecified (C25.9) Check the Alphabetic Index first before going to the Neoplasm Table

27. NeoplasmsCoding & Sequencing of Complications(Anemia Associated w/ Malignancy) ICD-10-CM When admitted for management of anemia associated with malignancy & treatment: Sequence the code for malignancy as principal Followed by appropriate code for anemia

28. Neoplasms Coding & Sequencing of Complications(Anemia assoc. w/ therapies) ICD-10-CM Management of anemia associated with adverse effect of administration of chemotherapy or immunotherapy and treatment is only for anemia, sequence the anemia code first, followed by appropriate codes for neoplasm and adverse effect Management of anemia associated with adverse effect of radiotherapy, sequence the anemia code first, followed by appropriate neoplasm code and code Y84.2, Radiological procedure and radiotherapy as cause of abnormal reaction of patient . . .

29. Neoplasms Malignancy in 2 or more noncontiguous sites ICD-10-CM In case where patient has more than one malignant tumor in the same organ, different tumors may constitute different primaries or metastatic disease, depending on site. If documentation unclear, query provider as to status so that coding is correct

30. Neoplasms Admission to Determine Extent of Malignancy ICD-10-CM When the reason for admission is to determine the extent of the malignancy, list the malignancy first, even if chemotherapy or radiotherapy is administered.

31. NeoplasmsSequencing of neoplasm codes (cont.) ICD-10-CM Malignant neoplasm in pregnant patient: use code from subcategory O9A.1-, Malignant neoplasm complicating pregnancy, childbirth, and the puerperium, sequenced first, followed by appropriate code from Chapter 2 to indicate type of neoplasm

32. NeoplasmsSequencing of neoplasm codes (cont.) ICD-10-CM Encounter for complication associated with neoplasm: When encounter is for mgmt of complication associated w/ neoplasm and treatment is only for complication, code complication first, followed by appropriate code for neoplasm Exception: Anemia (see slide above)

33. NeoplasmsSequencing of neoplasm codes (cont.) ICD-10-CM When encounter is for treatment of complication resulting from surgical procedure performed for treatment of neoplasm, designate complication as principal diagnosis. (See guideline regarding the coding of current malignancy vs personal history to determine if code for neoplasm should also be assigned)

34. NeoplasmsSequencing of neoplasm codes (cont.) ICD-10-CM Pathologic fracture due to neoplasm If focus of treatment is the fracture, code from subcategory M84.5, Pathological fracture in neoplastic disease, should be sequenced first, followed by neoplasm code - If focus of treatment is neoplasm with an associated pathological fracture, code neoplasm first, followed by code from M84.5 for the pathological fracture

35. Neoplasms Current malignancy vs. personal history of malignancy ICD-10-CM When primary malignancy has been excised but further treatment is directed to that site, use primary malignancy code until treatment is completed Use code Z85, Personal history of malignant neoplasm, to indicate former site of malignancy once it has been excised/eradicated, there is no further treatment directed to that site, and there is no evidence of existing malignancy

36. NeoplasmsLeukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history ICD-10-CM Categories for leukemia, and category C90, Multiple myeloma and malignant plasma cell neoplasms, have codes indicating whether or not the leukemia has achieved remission. There are also codes for personal history of leukemia or malignant neoplasms of hymphoid, hematopoietic and related tissues

37. NeoplasmsLeukemia, Multiple Myeloma, and Malignant Plasma Cell Neoplams in remission vs personal history (cont.) ICD-10-CM If it is unclear in the documentation as to whether or not the leukemia has achieved remission, query the provider.

38. Malignant Neoplasm associated with Transplanted Organ ICD-10-CM Coded as tranplant complication Assign the code for the specific malignancy second

39. Diabetes Diabetes Mellitus ICD-10-CM Diabetes mellitus codes are combination codes to include type of diabetes, body system affected, and complications affecting that body system Assign as many codes within category as are necessary to describe all complications of disease

40. Diabetes Underdose of insulin due to insulin pump failure ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x6-, Underdosing of insulin and oral hypoglycemic (antidiabetic drugs) as secondary Assign codes for type of diabetes mellitus and associated complications if appropriate

41. Diabetes Overdose of insulin due to insulin pump failure ICD-10-CM Assign code from subcategory T85.6, Mechanical complication of other specified internal and external prosthetic devices, implants, and grafts, that specifies type of pump malfunction as principal Assign T38.3x1-, Poisoning by insulin and oral hypoglycemic drugs, accidental as secondary

42. Diabetes Secondary Diabetes Mellitus ICD-10-CM Codes under categories E08, Diabetes mellitus (DM) due to underlying condition, and E09, Drug or chemical induced diabetes mellitus, show complications and manifestations associated with secondary diabetes mellitus Secondary DM is always caused by another condition

43. Diabetes Assigning and sequencing secondary diabetes codes and its causes ICD-10-CM Sequencing of secondary diabetes codes in relationship to codes for the cause of the diabetes is based on the Tabular List instructions for categories E08 and E09.

44. Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CM Assign code F45.41, for pain that is exclusively related to psychological disorders Do not assign a code from category G89, Pain, not elsewhere classified with is code

45. Mental & Behavioral Disorders Pain disorders related to psychological factors ICD-10-CM Code 45.42, Pain disorders with related psychological factors, should be used with a code from category G89, Pain, not elsewhere classified if documentation shows a psychological component for a patient with acute or chronic pain

46. Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM In Remission Assigned only if so documented. Selection of codes for “in remission” categories F10-F19, Mental and behavioral disorders due to psychoactive substance use

47. Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM Psychoactive Substance Use, Abuse and Dependence - When provider documentation refers to use, abuse and dependence of the same substance, only one code should be assigned to identify the pattern of use based on the following:

48. Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM Psychoactive Substance Use, Abuse and Dependence (cont.) If both use and abuse are documented, assign only the code for abuse If both abuse and dependence are documented, assign only code for dependence If use, abuse and dependence are all documented, assign only the code for dependence

49. Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM Psychoactive Substance Use, Abuse and Dependence (cont.) If both use and dependence are documented, assign only the code for dependence

50. Mental & Behavioral Disorders Mental & Behavioral disorders due to psychoactive substance use ICD-10-CM Psychoactive Substance Use The codes for psychoactive substance use should only be assigned based on provider documentation and when they meet the definition of a reportable diagnosis - Codes are to be used only when the psychoactive substance use is associated with a mental or behavioral disorder, and this relationship is documented by provider