Baby, Don’t Hurt Me: Challenges in ICD-10 Coding

1. Baby, Don’t Hurt Me: Challenges in ICD-10 Coding Presented by: Andrea Romero April 12, 2012 HFMA/NMHIMA Spring Conference

2. Objectives • Compare and contrast ICD-9 and ICD-10 general rules for obstetric cases from the coding guidelines for obstetrical coding • Provide specific examples of obstetrical coding in ICD-10 • Compare and contrast ICD-9 and ICD-10 coding guidelines for injury coding • Provide specific examples of injury coding in ICD-10

3. Obstetrical Coding

4. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • Codes from chapter 11 and sequencing priority • Obstetric cases require codes from chapter 11, codes in the range 630-679, Complications of Pregnancy, Childbirth, and the Puerperium. Chapter 11 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 11 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code V22.2 should be used in place of any chapter 11 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy. • Codes from chapter 15 and sequencing priority • Obstetric cases require codes from chapter 15, codes in the range O00-O9A, Pregnancy, Childbirth, and the Puerperium. Chapter 15 codes have sequencing priority over codes from other chapters. Additional codes from other chapters may be used in conjunction with chapter 15 codes to further specify conditions. Should the provider document that the pregnancy is incidental to the encounter, then code Z33.1, Pregnant state, incidental, should be used in place of any chapter 15 codes. It is the provider’s responsibility to state that the condition being treated is not affecting the pregnancy.

5. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • Chapter 11 codes used only on the maternal record • Chapter 11 codes are to be used only on the maternal record, never on the record of the newborn. • Chapter 15 codes used only on the maternal record • Chapter 15 codes are to be used only on the maternal record, never on the record of the newborn.

6. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • Chapter 11 fifth-digits • Categories 640-649, 651-676 have required fifth-digits, which indicate whether the encounter is antepartum, postpartum and whether a delivery has also occurred. • Final character for trimester • The majority of codes in Chapter 15 have a final character indicating the trimester of pregnancy. The timeframes for the trimesters are indicated at the beginning of the chapter. If trimester is not a component of a code it is because the condition always occurs in a specific trimester, or the concept of trimester of pregnancy is not applicable. Certain codes have characters for only certain trimesters because the condition does not occur in all trimesters, but it may occur in more than just one.

7. Timeframes for Trimesters • Trimesters are counted from the first day of the last menstrual period. They are defined as follows: • 1st trimester- less than 14 weeks 0 days • 2nd trimester- 14 weeks 0 days to less than 28 weeks 0 days • 3rd trimester- 28 weeks 0 days until delivery

8. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • Fifth-digits, appropriate for each code • The fifth-digits, which are appropriate for each code number, are listed in brackets under each code. The fifth-digits on each code should all be consistent with each other. That is, should a delivery occur all of the fifth-digits should indicate the delivery. • Assignment of the final character for trimester should be based on the provider’s documentation of the trimester (or number of weeks) for the current admission/encounter. This applies to the assignment of trimester for pre-existing conditions as well as those that develop during or are due to the pregnancy. The provider’s documentation of the number of weeks may be used to assign the appropriate code identifying the trimester.

9. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • N/A • Whenever delivery occurs during the current admission, and there is an “in childbirth” option for the obstetric complication being coded, the “in childbirth” code should be assigned.

10. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • N/A • Selection of trimester for inpatient admissions that encompass more than one trimesters • In instances when a patient is admitted to a hospital for complications of pregnancy during one trimester and remains in the hospital into a subsequent trimester, the trimester character for the antepartum complication code should be assigned on the basis of the trimester when the complication developed, not the trimester of the discharge. If the condition developed prior to the current admission/encounter or represents a pre-existing condition, the trimester character for the trimester at the time of the admission/encounter should be assigned.

11. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • N/A • Unspecified trimester • Each category that includes codes for trimester has a code for “unspecified trimester.” The “unspecified trimester” code should rarely be used, such as when the documentation in the record is insufficient to determine the trimester and it is not possible to obtain clarification.

12. General Rules for Obstetric Cases ICD-9-CM ICD-10-CM • N/A • 7th character for Fetus Identification • Where applicable, a 7th character is to be assigned for certain categories (O31, O32, O33.3 - O33.6, O35, O36, O40, O41, O60.1, O60.2, O64, and O69) to identify the fetus for which the complication code applies. • Assign 7th character “0”: • For single gestations • When the documentation in the record is insufficient to determine the fetus affected and it is not possible to obtain clarification. • When it is not possible to clinically determine which fetus is affected.

14. ICD-10-PCS Guidelines: Obstetrics section • Products of conception • C1 • Procedures performed on the products of conception are coded to the Obstetrics section. Procedures performed on the pregnant female other than the products of conception are coded to the appropriate root operation in the Medical and Surgical section. • Example: Amniocentesis is coded to the products of conception body part in the Obstetrics section. Repair of obstetric urethral laceration is coded to the urethra body part in the Medical and Surgical section.

15. ICD-10-PCS Guidelines: Obstetrics section • Procedures following delivery or abortion • C2 • Procedures performed following a delivery or abortion for curettage of the endometrium or evacuation of retained products of conception are all coded in the Obstetrics section, to the root operation Extraction and the body part Products of Conception, Retained. Diagnostic or therapeutic dilation and curettage performed during times other than the postpartum or post-abortion period are all coded in the Medical and Surgical section, to the root operation Extraction and the body part Endometrium.

18. Obstetric Section: Root Operations • There are twelve root operations in the Obstetrics section • Two Root Operations unique to this section • Abortion – artificially terminating a pregnancy • Delivery – assisting the passage of the products of conception from the genital canal • Other Root Operations same as Medical and Surgical Section • Change, Drainage, Extraction, Insertion, Inspection, Removal, Repair, Reposition, Resection, Transplantation

19. Obstetrical Case Study • A 36-year-old G2 P1 woman is 39 weeks pregnant. She has a dichorionic/diamniotic twin pregnancy with Twin #1 in breech presentation. She also has gestational hypertension. She is admitted due to active labor. Twin #2 is delivered vaginally over a midline episiotomy. Internal version is successfully performed on Twin #1 and the baby is also delivered vaginally. The episiotomy is repaired.

20. Obstetrical Case Study ICD-9-CM ICD-10-CM • 652.11 Breech presentation, with successful version • 651.01 Twin pregnancy, delivered • 642.31 Gestational hypertension • V23.82 Elderly multigravida • V27.2 Outcome of delivery, twins, liveborn • O32.1xx1 Breech presentation, fetus #1 • O30.043 dichorionic/ diamniotic twin pregnancy, third trimester • O13.3 Gestational hypertension, 3rd trimester • O09.523 Elderly multigravida, 3rd trimester • Z37.2 Outcome of delivery, twins, liveborn

26. Obstetrical Case Study ICD-9-CM Procedures ICD-10-PCS • 73.59 Manually assisted delivery • 73.6 Episiotomy with episiorrhaphy • 73.21 Version • 10E0XZZ Delivery • 0W8NXZZ Episiotomy • 0WQNXZZ Episiorrhaphy • 10S07ZZ Version

27. Delivery Because the procedure is being performed on products of conception a code from the Obstetrics section is used

28. Episiotomy Because the procedure is being performed on the mother a code from the Medical and Surgical section is used

29. Episiorrhaphy Because the procedure is being performed on the mother a code from the Medical and Surgical section is used

30. Version Because the procedure is being performed on products of conception a code from the Obstetrics section is used

31. QUESTIONS?

32. Coding Injuries

33. Application of 7th Character ICD-9-CM ICD-10-CM • N/A • Most categories in chapter 19 have a 7th character requirement for each applicable code. Most categories in this chapter have three 7th character values (with the exception of fractures): A, initial encounter, D, subsequent encounter and S, sequela. Categories for traumatic fractures have additional 7th character values.

34. Application of 7th Character ICD-9-CM ICD-10-CM • N/A • 7th character “A”, initial encounter is used while the patient is receiving active treatment for the condition. Examples of active treatment are: surgical treatment, emergency department encounter, and evaluation and treatment by a new physician.

35. Application of 7th Character ICD-9-CM ICD-10-CM • N/A • 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase. Examples of subsequent care are: cast change or removal, removal of external or internal fixation device, medication adjustment, other aftercare and follow up visits following treatment of the injury or condition.

36. Application of 7th Character ICD-9-CM ICD-10-CM • N/A • The aftercare Z codes should not be used for aftercare for conditions such as injuries or poisonings, where 7th characters are provided to identify subsequent care. For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).

37. Application of 7th Character ICD-9-CM ICD-10-CM • N/A • 7th character “S”, sequela, is for use for complications or conditions that arise as a direct result of a condition, such as scar formation after a burn. The scars are sequelae of the burn. When using 7th character “S”, it is necessary to use both the injury code that precipitated the sequela and the code for the sequela itself. The “S” is added only to the injury code, not the sequela code. The 7th character “S” identifies the injury responsible for the sequela. The specific type of sequela (e.g. scar) is sequenced first, followed by the injury code.

38. Coding of Injuries ICD-9-CM ICD-10-CM • When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Multiple injury codes are provided in ICD-9-CM, but should not be assigned unless information for a more specific code is not available. These traumatic injury codes are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. • The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first. • When coding injuries, assign separate codes for each injury unless a combination code is provided, in which case the combination code is assigned. Code T07, Unspecified multiple injuries should not be assigned in the inpatient setting unless information for a more specific code is not available. Traumatic injury codes (S00-T14.9) are not to be used for normal, healing surgical wounds or to identify complications of surgical wounds. • The code for the most serious injury, as determined by the provider and the focus of treatment, is sequenced first.

39. Injury Case Study • A 19-year-old male suffered a fracture of C3 with complete transection of the spinal cord at that level. The injury occurred due to a tackle in a football game. It happened on a football field. The patient is a student who is on a recreational football team.

40. Injury Case Study ICD-9-CM ICD-10-CM • 806.01 Fracture of C3 w/transection of spinal cord • E886.0 Tackle in sports • E007.0 Activities involving American tackle football • E849.4 Occurring at place for recreation and sport • E000.8 Sport, not for income, while a student • S12.200A Fracture C3 • S14.113A Transection of spinal cord • W03.xxxA Fall on same level due to collision • Y93.61 Activities involving American tackle football • Y92.321 Occurring at football field • Y99.8 Sport, not for income, while a student

41. Fracture C3

42. 7th Character

43. Transection Spinal Cord

44. 7th Character

45. Injury Case Study • 49-year-old male fell from a ladder inside a building construction site and suffered an open skull fracture with subarachnoid and subdural hemorrhage. He was unconscious for 32 hours and expired without regaining consciousness. He was an employed construction worker.

46. Injury Case Study ICD-9-CM ICD-10-CM • 803.75 Open skull fracture with subarachnoid and subdural hemorrhage, prolonged LOC w/o return to consciousness • E881.0 Fall from ladder • E016.2 Activities involving construction • E849.3 Occurring at building under construction • E000.0 Civilian activity for pay • S02.91xB Open skull fracture • S06.6x7A Subarachnoid hemorrhage w/o return to consciousness • S06.5x7A Subdural hemorrhage w/o return to consciousness • W11.xxxA Fall from ladder • Y93.H3 Activity, construction • Y92.61 Occurring at building under construction • Y99.0 Civilian activity for pay

47. Skull Fracture

48. 7th Character

49. Subarachnoid Hemorrhage

50. Subdural Hemorrhage